IntroductionClinical laboratory diagnosis (CLD) – independent area of

medical science is based on such fundamental disciplines, as medical biochemistry, pathological physiology, immunology, pathological anatomy, etc. Past years, this direction of medicine promptly developed in connection with new opening in biology, increase in volume of information, development of new methods of research, differentiation and specialization of medical service. Doctors of a different structure should have knowledge with CLD, be guided in modern methods of laboratory diagnosis, be able to choose correctly and meaningly methods of all-round inspection of patients, to interpret results of analysis, for necessities to pick up additional reserches for purpose (assignment) of adequate and effective therapy, monitoring of treatment.

Priority direction of medicine of XXI century becomes preventive medicine - prepared doctors – preventive maintenance, the family or domestic doctor. In this case the main object of medical attention becomes not only the patient, and the healthy person, the basic problem (task) of the doctor – an establishment, mainly, on the basis of the physical and chemical laboratory data of an individual to the certain pathology, diagnostics of hereditary defects of metabolisms risk factors, etc.

The purpose of CLD is mastering the unified and new methods of research of biological materials, consideration of pressing questions of clinical biochemistry, ordering and deepening of theoretical knowledge for competent interpretation of results of biochemical analysis, optimization of laboratory inspection, acquaintance with modern constellations and differential-diagnostic biochemical programs which are used for diagnostics and treatment of patients, improvement of practical habits and skills.

Rate of CLD (clinical biochemistry) will consist of 15 practical classes, each of which stipulates laboratory research of biological materials, reception and interpretation of results; the three-sedate control of knowledge over the base test – control, consideration of theoretical questions, decisions of situational problems (task) “with

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the open textbook” with further discussion, an estimation, the analysis of results, substantiation and treatment of a clinical situation; drawing up block diagrams, comparative tables of changes of laboratory parameters at different pathological conditions, selection of the most informative сonstellation biochemical tests for an estimation of infringements of biochemical processes and physiological functions of an organism.

Within the limit rate of CLD, there is also an independent work of students which is estimated by results of obligatory home work (OHW). At the end CLD rate differential credits are

In the given methodical recommendations are the stated basic stages of preparation of students to practical classes:

1 Questions for study theme / the Questions for preparation2 Test questions to estimate students mastering of the material by

the teacher3 The description of laboratory works, with basic practical which

receptions of performance the student gets acquainted with in class

4 Clinico-diagnostic value of separate parameters, pharmacolo-gical and chemical interference

5 Situational tasks with clinical history6 List of the basic and additional literature which is recommended

for studying a themeAt the end of methodical recommendations questions to

independent work on CLD, normal values of biochemical parameters of blood and urine – the most effective combinations of tests in diagnosis of diseases (on D.L. Komarov and L.P. Aksyonenko) move.

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List of practical topics№ Theme of lessons Number

of hours1

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6

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Biochemical tests in clinical medicine. Monitoring of medical drugsNormal and pathological indexes of proteins and nonprotein nitrogen metabolismClinical enzymology. EnzymodiagnosticsClinical and laboratory diagnosis of breaches in carbohydrate metabolismLaboratory investigations and biochemical diagnostics of breaches in lipids and lipoproteins metabolismDiagnostic criteria of disturbance of water, sodium, potassium metabolism. Determination of acid-base balanceClinical-laboratory diagnostics of disorders of hemoproteins metabolism, porphyrines and iron. Clinical-laboratory diagnosis of nucleotides metabolism disorders Clinical-laboratory diagnostics of hypothalamus, hypophysis, adrenal and sexual glands disordersClinical-laboratory diagnostics of functional activity of thyroid and parathyroid glands. Biochemical investigations of disorders of calcium, phosphates and magnesium metabolismA clinical estimation of biochemical indexes is at liver and biliary ways diseasesA clinical estimation of biochemical indexes in kidneys diseasesDisorders of gastrointestinal tract functions, their diagnostics and diet therapyLaboratory diagnostics of the inherited metabolic diseases. Features of clinic-laboratory diagnostics of diseases of extreme age. Biochemical aspects of pregnancy and early child's ageBiochemical indexes under oncologic diseases. Clinical-laboratory diagnosis of the cardio-vascular system, connective tissue, breathing organs diseasesConclusion session

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Lesson 1Topic. Biochemical tests in clinical medicine.

Monitoring of medical drugs.

Questions for preparation1 Application of biochemical analyses in diagnostics, screening,

prognosis and monitoring of the diseases.2 Types of biological material. General claims for selecting samples.3 General claims for analysis of samples and arrangement of the

results.4 Interpretation results of samples.5 Specificity, sensitivity and prognostic value of the biochemical

analyses.6 Errors of laboratory diagnostics.7 New trends in development of clinicodiagnostic laboratories.8 Prospects of development of biochemical methods of noninvasive

diagnostics.9 Monitoring of the medical drugs. Screening for presence of

pharmacological drugs in the organism.

Test questions1 Mention the main functional assignments of the biochemical tests.2 Name the rules of listing up the inquiry for analysis.3 Name the factors which influence the results of biochemical study.

Give some examples.4 Enumerate the main rules of taking samples to perform

biochemical analysis of blood.5 Name the main characteristic of the “ideal” analytic method.6 Explain the notion “analytical variability” in the biochemical

analysis.7 Explain the notion “biological variability” in the biochemical

analysis.8 Explain the notion “specificity of diagnostic test”.9 Explain the notion “sensitivity of diagnostic test”.

10 Explain how the effectiveness of analysis can be estimated.

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11 Name the main claims of the screening tests.12 Mention the cases in which estimation of medical drugs in liquid

media of the organism is essential.13 Name the claims for the methods of estimation of concentration

of medical drugs in plasma.14 What concentration of pharmacological drugs in plasma is

defined as “therapeutic” value?15 Justify the importance of performing the monitoring of phenytoin.16 Name the anticonvulsant drugs, concentration of which must be

estimated in plasma. Justify your answer.17 Name the pathological and physiological factors which influence

on sensitivity to digioxin.18 Justify the importance of performing monitoring of digioxin.19 Justify the importance of performing monitoring of lithium.20 Justify the importance of performing monitoring of theophylline.21 Justify the importance of performing monitoring of cyclosporine.22 Justify the importance of performing monitoring of

aminoglycoside antibiotics.23 Justify the importance of performing monitoring of methotrexate.24 Describe the opportunities of noninvasive diagnostics during

monitoring of medical drugs.25 Explain the biochemical mechanisms of toxicity of paracetamol

when it’s overdosed.26 Explain the biochemical mechanisms of influence of the

salicylates on metabolic processes when they are overdosed.27 Explain the biochemical mechanisms of influence of the

salicylates on the processes of oxidative phosphorylation when they are overdosed.

28 Explain in what cases monitoring of alcohol is expedient.29 Explain in what cases screening for medical drugs in blood is

necessary.30 Describe the general principles of performing electrophoresis.

Name the drawbacks of performing paper electrophoresis and benefits of gel electrophoresis.

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31 Give the examples for application of method of electrophoresis in diagnostics.

32 Describe the general principles of performing adsorption chromatography.

33 Describe the general principles of performing partition chromatography.

34 Describe the opportunities of application of chromatographic methods in clinical laboratory examinations.

35 Mention the principle of radioimmunoassay. Give the examples of its application in clinical laboratory examinations.

36 Mention the principle method of atomic adsorption analysis, give the examples of its application for studying the mineral composition of blood.

LiteratureI - p. 1-12, 301-304

Lesson 2Topic. Normal and pathological indexes of proteins and

nonprotein nitrogen metabolism

Questions for preparation1 Biological role of plasma proteins in an organism.2 Characteristics of methods of proteins research (electrophoresis,

immunoelectrophoresis, chromatography).3 Technique and conditions for performing electrophoresis of blood

serum proteins. Graphical presentation of the results obtained.4 Clinical significance of the determination of the total blood serum

proteins. Main causes of hyper- and hypoproteinaemia.5 Characteristics of the main blood fractions of proteins.6 Explain what are disproteinaemias, paraproteinaemias, M-gra-

dient, and Bence Jones proteins.7 Electrophoregrams of blood serum proteins in normal and in

pathological state.

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8 Characteristics of the most investigated separated proteins of blood plasma and their applications for diagnostics.

9 Explain what is proteinuria. Uroproteinograms.10 Proteins of other liquid mediums in an organism.11 Nonprotein nitrogen of blood. Classification of azotemias.12 Clinical significance for the definition of the rest nitrogen

components in blood (urine, free amino acids, creatine, creatinine, indican, ammonia, uric acid).

Perform and interpret the results of these experiments:1. Determination of the total proteins in blood serum by the

biuretic method.Method principle: the method is based on formation of a violet-

coloured complex of peptide bonds of protein with copper sulphate in an alkaline medium. The intensity of the colour is directly proportional to the protein concentration in blood serum and is estimated by the photometric method.

Process of work: 1 ml of blood serum is placed into the first tube (test sample), and into the second one – 0,1 ml of standard protein solution (standard sample), into the third one – 0,1 ml of the 0.9% solution of sodium chloride (control sample). In each of these tubes, 5 ml of a biuretic reagent is added, then the contents of the tubes is carefully mixed and after 30 minutes extinction is estimated with the help of photoelectrocalorimeter in the cuvettes in 10 ml through a green colour filter (540 nm) against the control solution.

Calculations are made according to the formula:

,

where Cex is concentration of protein in the examined blood serum, g/l;Eex is extinction of the examined blood serum;Cst is standard concentration of protein in the standard solution, g/l;Est is extinction of standard protein solution.

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Clinical-diagnostic significance. Concentration of proteins in the blood serum of adults are 65-85 g/l. Increase of the total protein concentration in blood serum (hyperproteinemia) can be relative (water loss in case of burns, diarrhea) or absolute (myelomatosis, infectious diseases and rheumatism). Hypoproteinemia is decrease of the protein concentration in blood serum, it occurs mainly due to decrease of albumins and together with nephrotic syndrome, liver pathologies, increased permeability of vascular walls, protein starvation.

Pharmacological interference. The results of investigation are overestimated by: amino acids (when introduced intravenously), anabolic steroids, androgens, ACTH (adrenocorticotropic hormone), acetylsalicylic acid, butamide, imipramine, insulin, corticotropin, corticosteroids, progesterone, roentgenopaque drugs, chloramphenicol, streptomycin sulphate, sulfanilamides, tetracycline, phenothiazines, miscleron, bromsulfalein.

The results of research are underestimated by: trasinamide, ammonium ions, purgatives.

2. Distribution of the proteins fractions using the method of electrophoresis in a polyacrylamide gel

Normal index: albumins – 35-50 g/l (52-65%); globulins – 23-35 g/l (35-48%)

Clinical-diagnostic significance. With the help of electrophoresis proteins of blood serum are separated into fractions which give characteristic for the state of an organism and are used for diagnostics. Decrease in number of albumins points to liver diseases or their loss with urine in renal pathologies. Increase in the number of γ-globulins is observed in infectious processes and decrease of this fraction can indicate AIDS. Significant decrease of albumins and increase of all globulin fractions occur with malignant tumors.

Pharmacological interference. Increase of α1-globulins is detected when peroral contraceptives are ingested. Decrease of γ-globulins content is observed with corticoid or ACTH treatment.

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3. Sedimentation tests: thymol, sulemic, Weltman’s tests.3.1. Thymol testMethod principle: pathologically increased β-globulins, γ-globu-

lins and lipoprotein are precipitated from blood serum in pH=7.55 buffer solution that saturated by thymol. The intensity of opacification is measured which depends on the content of proteins fractions and their correlation.

Process of work: 4,8 ml of thymol reagent are put into a tube, then 0,08 ml of blood serum is added and then mixed. They are left for 30 minutes at room temperature. Then the solution is processed by photocalorimeter against a thymol reagent at 630-690 nm. The intensity of opacification is determined according to the gauging graph.

Clinical-diagnostic significance. Normal index – 0-4 units S-H (after Shank and Hoagland). Considerable increase of the index is observed when the liver parenchyma is affected, especially in cases of acute hepatitis. The level of this increase correlates to the extent of the organs affection. The test is positive in 90-100% cases in Botkin’s disease (on the preicteric stage and anicteric form).

It is used for the differential diagnosis between obstructive jaundice and hepatocellular jaundice. In case of obstructive jaundice the index is within the bounds of norm and it becomes positive if the process is complicated with hepatocellular jaundice. In the case of obstructive jaundice, the thymol test is negative, Burstein’s test (for β- and pre-β-lipoproteins) is sharply positive, in case of hepatocellular jaundice both tests are positive. The thymol test is not specific for liver diseases and is of importance for all diseases which are accompanied by disproteinemia.

The index is increased in case of chronic hepatitis, liver cirrhosis, a less considerable increase is observed in cases of collagenoses, malaria, viral infections.

Pharmacological interference on the received results. The results of investigation are overestimated by: anabolic steroids, androgens, phenylbutazone, heparin, phenytoin, indometacin, insulin, MAO inhibitor, clofibrate, corticotrophin, corticosteroids, lincomycin hydrochloride, chloramphenicol, mercaptopurine, methyluracyl,

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methyldopa, procainamide hydrochloride, oleandomycin phosphate, progesterone, sulfonamides, tetracycline, phenothiazines, chlorpro-pamide, erythromycin, oestrogens.

3.2. Sulemic testClinicodiagnostic significance. Normal indices: 1,6-2,2 ml

HgCl2. In cases of Botkin’s disease – 1,0-1,65. With recovery it goes back to norm. Sulemic test is positive in cases of liver cirrhosis, silicosis.

3.3. Weltman’s testMethod principle: adding of CaCl2 to the blood serum and their

heating results in the disturbance of the colloid constance of proteins in blood serum.

Process of work: 0,1 ml of blood serum and 4,9 ml H2O are put into a tube; thoroughly shaken off and 0,1 ml 0,5 % CaCl2 are added. It’s all heated till the first boiling of the mixture. Then it’s cooled, if there is no opacification, 0,1 ml CaCl2 is added and boiled again. The process of adding CaCl2 and boiling is repeated until white flakes appear. The result is expressed through amount of added CaCl2 (ml).

Clinical-diagnostic significanceNormal indices are 0,4-0,5 ml CaCl2. The increased indices are

observed in cases of rheumatism, pulmonary tuberculosis.The decreas is observed in cases of malaria, parenchymatous liver

damage.4. Determination of the rest nitrogen (residual nitrogen) in

blood Clinical-diagnostic significance. The increase of the rest nitrogen

of blood – azotemia – can be of two types: absolute (accumulation of rest nitrogen components in blood) or relative (dehydration of the organism, for example in case of emesis, diarrhea). Absolute azotemia is subdivided into retentive and productive. Retentive azotemia occurs as a result of insufficient excretion of nitrous compounds with urine in case of their normal falling into blood. Retentive azotemia can be renal and nonrenal.

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Productive azotemia is conditioned by rebundant falling of decay products of tissue proteins into blood. The function of kidneys is not affected at the same time. Azotemia of such type is observed in cases of cachexia, leucosis, malignant tumors, treatment with glucocorticoids.

The decrease of rest nitrogen is observed in cases of nutrition deficiency and sometimes in case of pregnancy.

Clinical interference: increase of rest nitrogen is caused by nephrotoxical medical drugs (heavy metals, analgesics, antibacterial agents, contrast agents, organic solvents, etc.)

Chemical interference: ethylene diamine tetraacetate (EDTA), which leads to the overestimating the rest nitrogen index.

Norm. The content of rest nitrogen in blood is 14,2-28,5 mmol/l, or 20-40 mg/l, or 0,2-04 g/l.

5 Definition of the C-reactive protein Clinical-diagnostic value. Increased level of C-reactive protein is

observed in cases of intrauterine infections (its level in blood from umbilical cord can reach 25600 mg/100 ml); in cases of acute inflammatory diseases (rheumatism, rheumatoid arthritis), tumors, acute myocardial infarction (≈15000 μg/100 ml), some viral infecti-ons and immunodeficiency states (insignificant increase of its level).

Test questions1 What proteins detected in the composition of the α1-, α2-, β- and γ-

globulins fractions can be diagnostically useful?2 What does the notion “disproteinaemia” mean?3 What sequences does hypogammaglobulinaemias have?4 Name the causes of secondary hypogammaglobulinaemia.5 In case of what diseases are there increased contents of

gammaglobulins observed?6 What does the notion “paraproteins” mean? How are they

classified?7 How can the M-gradient located in the area of β-globulins be

detected?8 How can the Bence Jones protein be detected?

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9 What is “selective” and “nonselective” proteinuria?10 How can a multiple myeloma be detected using laboratory

methods?11 What are the main causes of hypoproteinaemia?12 What are the main causes of hyperproteinaemia?13 Depict the electrophoregram of blood serum in case of nephrotic

syndrome. Explain it.14 Depict the electrophoregram of blood serum in case of an acute

inflammatory process. Explain it.15 Depict the electrophoregram of blood serum in case of a chronic

inflammatory process. Explain it.16 Depict the electrophoregram of blood serum in case of liver

cirrhosis. Explain it.17 Depict the electrophoregram of blood serum in case of a

malignant tumor. Explain it.18 Depict the electrophoregram of blood serum in case of a myeloma.

Explain it.19 Depict the electrophoregram of blood serum in case of an

myocardial infarction. Explain it.20 Depict the electrophoregram of blood serum in the case of a

coronary heart disease (CHD). Explain it.21 Name the main causes and consequences of hypoalbuminaemia.22 Concentration of albumins in blood serum is used as a test of

functional state of liver. In what case is it expedient to use such index – for diagnosing acute or chronic affections of liver? Justify your answer.

23 Explain the biological role of “proteins of acute phase”, give examples of their application in diagnostics.

24 Explain in what cases are the increase and decrease in number of 1-antitrypsin are used as a diagnostic test.

25 Give the examples of use of -fetoprotein in dagnostics.26 Explain the biological role of 2-macroglobulin, its use in

diagnostics.27 Explain the biological role of haptoglobin, its use in diagnostics.

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28 State the diagnostic importance of detection of C-reactive protein in blood serum.

29 Name the causes of hypo--globulinaemia. Explain why the method of electrophoresis cannot be used for diagnosing hypo--globulinaemia?

30 Name the causes of hyper--globulinaemia.31 A patient with an myocardial infarction has increased fraction of

-globulins of blood serum to 17%. At the expense of what proteins does such increase occur? What test must be made for the control of the acute phase of this process?

32 State the clinical-diagnostic significance (CDS) for the detection of 2-microglobulin.

33 State the CDS of fibrinogen detection.34 State the CDS of paraproteins detection and the causes of

paraproteinemias.35 What examinations are used for detecting paraproteins in the

diagnostics of a multiple myeloma?36 State the CDS of the Bence Jones protein detection.37 Name the diagnostic criterias for benign paraproteinaemia.38 Explain how are the protein metabolism indexes in case of a

multiple myeloma. Explain it.39 State the CDS of the detection of cerebrospinal fluid proteins.40 Give the characteristics of disproteinaemia in case of infectious

hepatitis. What is the importance of detecting concentration of albumins in such patients during the recovery period?

41 Give the characteristics of disproteinaemia in case of infectious hepatitis of medium severity.

42 Give characteristics of disproteinaemia in case of lingering hepatitis.

43 Explain the significance of using the sedimentation tests in diagnostics.

44 Give characteristic of disproteinaemia in case of liver cirrhosis.45 Give characteristic of disproteinaemia in case of acute leukemia.46 Give characteristic of disproteinaemia in case of chronic leukemia.47 Give reasons for the emergence of proteinuria.

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48 Give characteristic of the blood proteins spectrum and uroproteinogram in case of highly selective proteinuria.

49 Give characteristic of blood proteins spectrum and uropro-teinogram in case of selective proteinuria.

50 Give characteristic of blood proteins spectrum and uroproteino-gram in case of nonselective proteinuria.

51 Explain the diagnostic importance of detecting the blood and urine proteins spectrum in case of nonselective proteinuria.

52 Name the typical changes in indices of rest nitrogen in case of retentive azotemia.

53 Name the typical changes in indices of rest nitrogen in case of productive azotemia.

54 State the CDS of detecting urea in blood serum.55 State the CDS of detecting uric acid in blood serum.56 State the CDS of detecting free amino acids and amine nitrogen in

blood and urine.57 State the CDS of detecting creatine and creatinine in blood serum

and urine.58 State the CDS of detecting ammonia in blood serum.59 State the CDS of detecting indicans in blood serum.60 In which of the following diseases does renal retentive azotemias

occur: a) acute nephritis; b) chronic nephritis; c) pneumonia; d) hydronephrosis; e) pyelonephritis; f) renal amyloidosis; g) renal tuberculosis?

61 In which of the following diseases cases of what diseases can nonrenal retentive azotemias be observed: a) diseases of digestive system (pyloric stenosis, bowel obstruction, dysentery, cholera); b) hemorrhages; c) thyrotoxicosis; d) considerable burns; e) Addison’s disease; f) diabetes; g) pneumonias?

62 What components of the rest nitrogen fraction dominate in case of productive azotemias: a) amino acids; b) urea; c) ammonia; d) uric acid; e) creatinine; f) peptides?

63 Is productive azotemia observed in the following states: a) fever; b) liver diseases; c) malignant masses; d) thyrotoxicosis; e) intoxications; f) abscesses, bronchiectases?

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64 In which diseases is it necessary to examine the ammonium level in blood serum : a) pancreatic diseases; b) liver diseases; c) state of shock; d) overheating of the organism (thermal and sun); e) poisoning, intoxications; f) porphyries?

65 What is the purpose of the detection of creatinine in blood and urine in a clinic: a) for updating the diagnosis; b) for estimation of the clearance; c) for control over estimation of diurnal diuresis; d) for estimation of the renal filtration value; e) for estimation of the renal blood flow value; f) for estimation of excretory function of kidneys?

66 In what cases is the content of creatinine in urine decreased: a) liver diseases (necroses); b) acute infectious myositis; c) adenosine triphosphate (ATP) deficiency in the organism; d) deficiency of the vitamins (A, C, B, E); e) abnormal penetrability of muscular membrane; f) kidney diseases?

67 How is the clearance of different substances estimated with regards to the creatinine clearance: a) if it is larger than the creatinine clearance, the substance under examination is secreted in tubules; b) if it is smaller than the creatinine clearance, the substance is reabsorbed in the tubules; c) if it is smaller than the creatinine clearance, the substance is oozed through tubules?

68 What is the purpose of the endogenic creatinine estimatation: a) for the estimation of the reabsorbtive function of tubules; b) for the estimation of the kidney filtration value; c) for the estimation of the number of functioning nephrons; d) for estimation of the value of renal blood flow; e) for estimation of the concentrational function of kidneys; f) for estimation of maximum reabsorption of glucose?

69 Name the diseases in which the detection of uric acid is to some extent of diagnostic importance: a) chronic leukemias; b) pneumo-nias; c) burns; d) erythemias; e) hemolytic anemias; f) hepatitis; g) lead poisoning; h) kidney diseases; i) progressive muscular atrophy; j) gout.

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70 The outcome of what diseases is complicated with hypoalbumi-naemia: a) systemic blood diseases; b) pyelonephritis; c) chronicnephritis with nephritic component; d) burns; e) chronic hepatites, cirrhoses; f) malignant diseases of stomach, intestine?

71 In what diseases is there decrease of the а1- and а2-globulines fraction possible: a) cirrhoses; b) lymphatic leukemias; c) hemo-globinurias; d) malignant diseases, complicated with dystrophy; e) Botkin’s disease; f) acute nephritis; g) dysfunction of thyroid gland; h) multiple myeloma?

72 In what diseases does the α-globulin fractions most distinctly increased: a) acute inflammatory processes; b) malignant tumors; c) chronic nephritis with nephritic syndrome; d) myocardial infarction?

73 What proteins appear in urine in case of nonselective proteinureas: a) albumins; b) α2- and β-globulins; c) α1-globulins; d) fibrinogen; e) gamma globulins; f) α-macroglobulins; g) cryoglobulins?

74 What proteins form β-globulins: a) fibrinogen; b) lipoproteins; c) C-reactive protein; d) transferrin; e) β2-microglobulin; f) α-fetoprotein?

75 What complications cause the appearance of paraproteins: a) hemorrhagic diathesis; b) nephrosclerosis; c) hypoproteinemia; d) hypercalcemia; e) syndrome of increased viscosity; f) loss of immunity?

Analysis of case historyI – p. 240.- № 13.1.

Situational problems1. A patient is 22 years old. He has been ill for several months.

Subfebrile temperature.Cervical lymph nodes are considerably enlarged, and of thick consistency. Liver snd spleen are not enlarged. Inconsiderable anemia. Leucogram is without particular changes. Erythrocyte sedimentation rate (ESR) is 45 mm/h. Total protein is 90,4 g/l; albumins – 49%; globulins α1- 4 %; α2 – 15%; β – 10%; γ - 22 %. What diagnosis can be assumed? What subsidiary examinations must be made to make the diagnosis accurate?

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2. What are the most typical changes in proteinograms observed with patients ill for carcinoma of lungs and how quickly are they detected?

3. A patient with acute pancreatitis. Total protein is 58 g/l. Hypoalbu-minemia is detected with increased fraction of β- and reduced α-globulins. How quickly does the changes in the albumins spectrum of blood occur? How can their reliability be checked? Can they be made a criteria for prognosis?

4. 16-year-old patient. Rheumatic disease. Cardiac muscle form. Mitral valve insufficiency. Malignant, progressive flow. Give an approximate proteinogram, received before beginning of glucocorticoid treatment and after it.

5. 42-year-old patient. Poor condition. Pale, slurred, persistent pains in bones; weakness. Malfunctions of both kidneys were detected. Hemoglo-bin – 56 g/l, leukocytes – 6,7∙109/L (neutrophils, stabs are increased in number). Erythrocyte sedimentation rate (ESR) – 70 mm/h. Total protein – 76 g/l, creatinine – 0,44mmol/l. Discharged from hospital with the diagnosis of chronic nephritis, without improvements, Two months later he admitted into another hospital with acute pain in bones. The patient was additionally examined. In his blood analysis were detected: leukocytes – 4,4∙109/L; myelocytes – 1,5%; metamyelocytes – 4%; eosinophils – 4%, basophils – 0,5%; stabs – 17,5%; segmented neutrophils – 29%; lymphocytes (l) – 39%; monocytes (m) – 4%; plasmocytes – 5%. With the help of electrophoresis of plasma proteins M-gradient was detected.

What mistake was made during the first examination of the patient? What diagnosis was made? Did the data of blood examination help to make the right diagnosis without paracentesis of marrow?

6. 30-year-old patient. Three weeks ago she had angina. Complains of headache, weakness, joint pains, high temperature (to 39,5 °С). Joints are painful for palpation. Peripheral lymph nodes are slightly enlarged. Liver protrudes out under the costal margin at 3 cm, spleen – at 2 cm.

Hemoglobin – 60 g/l, leukocytes - 3,2 ∙ 109 (eosinophils – 3%, stabs – 14%, segmented neutrophils – 62%, lymphocytes – 19%, monocytes – 2%). Erythrocyte sedimentation rate (ESR) – 38 mm/h. Bilirubin – 28 micro-mole/l; total protein – 68 g/l, albumins – 38%; globulins – 62% ((α1 - 47,2 %; α2 - 15 %; β - 15,7 %; γ - 22,1 %). Fibrinogen – 1g/l; C-reactive protein +++. Titer of antistreptolysin – 326 units, antistreptohyaluroni - dase – 875 units. Urea is in norm.

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What symptoms of the patient do not belong to clinical picture of rheumatism? What diagnosis can be presumed?

7. 7-year-old patient. Suddenly edemas on extremities and on the face appear, which periodically reduce and then enlarge. After a month from the onset of the disease, shortness of breath, weakness appear. With a diagnosis of chronic glomerulonephritis the patient was placed in a hospital. During examination enlarged liver was detected. Blood: Hb – 100 g/l, globular value – 1,05; leukocytes – 9,1∙109 (stabs - 2 %, segmented neutrophils – 90%, lymphocytes – 8%), total protein – 28,0 g/l, albumins – 12 (43%), α1-2

– globulins – 6,7 (24%), β-globulins – 5,0 (18%), γ-globulins – 4,3 (15%). Urine is unchanged. Numerous analyses of total proteins gave the same results. The carrying out of complex treatment eliminated all the symptoms.

What treatment cured the patient? What diagnosis was made: a) kwashiorkor; b) idiopathic hypoproteinemia?

8. 3-year-old patient. Infancy was normal. Weight 5100 g, height 60cm. At the age of 5,5 months after introduction of additional feeding muscular hypotonia, swallowing disorder developed. At the age of 1 convulsive attacks appeared. The data of electroencephalogram indicated diffuse lesion of brain, typical of children with development delay. At the examination of amino acids spectrum the increase in level of histidine in blood (150 mg/l) and its daily excretion with urine (510 mg) were detected. During chromatography of sweat and urine a specific test was detected – absence of urocanic acid. Hystidinase activity in the corneal layer of skin was not detected. When a corresponding diet was prescribed, positive dynamics in psychomotor development was observed.

What was the diagnosis? What treatment was carried out?9. A 65-year-old man came to the doctor with complaints of back pain,

loss of weight. During the last months the patient had acute respiratory diseases (ARD) several times. As time went by shortness of breath during physical activity developed. At the examination anemia was detected. In blood serum: Hb= 80 g/l; ESR100 mm/h; albumins – 30 g/l; total protein – 95 g/l; paraproteins in the area of -globulins, urea – 15,0 mmol/l; creatinine – 215 mmol/l; Na – 130 mmol/l; Ca – 2,8 mmol/l. During the X-ray examination detected lytic perforation damages in vertebras, pelvic bones and ribs.

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During electrophoresis of blood serum the following electrophoregram was received:

Albumins 1 2 -globulins

Start Comment on the received data of laboratory investigations. Interpret the

results of the blood protein electrophoresis. What diagnosis can be presumed? What additional laboratory examinations can be carried out to make the diagnosis more exact?

10. During electrophoresis of blood serum the following electrophoregram was received:

Albumins 1 2 -globulins

Start

Comment on the received results of laboratory investigations. Interpret the results of the blood protein electrophoresis.

11. During electrophoresis of blood serum the following electrophoregram was received:

Albumins 1 2 -globulins

StartComment on the received results of laboratory investigations. Interpret

the results of the blood protein electrophoresis.12. At the examination of a patient, the liver was enlarged by 10 cm,

decreased sulemic test, total blood protein – 90 g/l. Electrophoresis of blood serum detected the following:

Albumins 1 2 -globulins

Start

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Comment on the received results of laboratory investigations. Interpret the results of the blood protein electrophoresis. What diagnosis can be presumed? What additional laboratory examinations can be carried out to make the diagnosis more exact?

LiteratureI – p. 215-225.

Lesson 3Topic. Clinical enzymology. Enzymodiagnostics.

Questions for preparation1 General characteristic of enzymes. Isoenzymes.2 Application of enzymes in clinical practice.3 Enzymodiagnostic. Classification of the plasma enzymes. Types

of changes in activity of blood enzymes in cases of different pathologies.

4 General characteristic of the enzymes which are of diagnostic significance: alkaline and acid phosphatases, transaminases, gamma-glutamyl transpeptidase (GGTP), lactate dehydrogenase (LDH), creatine kinase (CK), amylase, choline esterase, sorbitoldehydrogenase (SDH), transamidinase.

5 Changes in enzymatic activity during diseases of liver, heart, muscles, bones, kidneys, pancreas, oncological diseases.

6 Enzymes of other biological fluids and tissues.7 General principles of estimation of enzymatic activity in blood

serum. Units of activity of enzymes. Drawbacks of enzyme analysis.

Perform and interpret the results of examinations1. Estimation of transaminases activity in blood serumPrinciple of the method: as a result of preamination under the

effect of aspartate aminotransferase (AST), asparaginic acid is transformed into oxaloacetic acid (OAA), and alanine under the effect of alanine aminotransfcrase (ALT) – into pyruvic acid.

22

OAA can in the course of enzymatic reaction transforms into pyruvic acid (PVA). After addition of acid 2,4-dinitrophenilhydrasine (2,4-DPH) zymotic process stops and dinitrophenilhydrazone of pyruvic acid is formed. In alkaline medium it gives a mahogany colour. Its intensity is directly proportional to the amount of formed pyruvic acid.

The amount of PVA lets us make conclusions about the activity of the enzyme. Activity of aminotransferase is expressed in micromoles of pyruvic acid, formed from 1 ml of blood serum within 1 hour of incubation at the temperature of 370С.1.1. Estimation of aspartataminotransferase activity (AST)

Process of work: the work is carried out according to the table.Reagent Test sample (ml) Control sample (ml)Substrate

mixture (aspartic acid + α- ketoglutaric acid)

0,5 0,5

Place into the thermostat for 5 minutes at a temperature of 370С

Blood serum H2O (distilled)

0,1-

-0,1

Place into the thermostat for 30 minutes at a temperature of 370С

2,4-DPH 0,5 0,5Place into the thermostat for 20 minutes at a temperature of

250С0,4n NaOH 5 5Note. It is to be thoroughly mixed for 10 minutes at a temperature

of 250С (for the colour to form). Optical density is measured with the help of a photoelectrocalorimeter at λ=500-560 nm (green colour filter) against control in the cuvettes with a layer thickness of 10 mm

23

Calculation of the enzymatic activity is carried out according to the formula:

Х = Е ∙ 133 un/ml,Where X – enzymatic activity;E – extinction;133 – conversion rate.1 μM of PVA – 0,015 un. E; 1 un. E – 133 μg of PVA,

or according to the calibration diagram. Activity is expressed in standard units, making calculations for 1 ml of serum. 1 unit of AST corresponds to such enzymatic activity, which under certain conditions can form 1 μg of PVA (pyruvic acid). In the process of calculation of the enzymatic activity serum dilution must be also taken into consideration:

Х = а ∙ 10,Where X – enzymatic unit;10 – conversion for 1 ml;a – amount of PVA, found in the calibration diagram, mcg.

Normally AST activity – 5-40 un/ml (0,1-0,5 μM/ml). Conversion of enzymatic activity in micromoles of PVA, which were formed during incubation of 1 ml of serum for 1 hour at the temperature of 370С, is carried out according to the formula:

,

Where, a – amount of PVA, found in the calibration diagram, mcg;88 – weight of 1 micromole of PVA, μg;10 – conversion rate for 1 ml of serum;2 – only for ALT – conversion rate for 1 hour of incubation.

1.2. Estimation of alanine aminotransferase activity (ALT)Process of work: estimation of ALT activity is carried out

similarly to that of AST except that the another substrate mixture (alanine and α-ketoglutarate) is taken.

24

Calculation of the activity is made according to the prepared calibration curve. For the calculation of ALT activity and its conversion into micromoles of pyruvic acid the same formulas as for AST are used. One unit of ALT corresponds to such enzymatic activity, which can under the conditions of the experiment form 1 mcg of PVA. Normal ALT activity – 30 un/ml (0,1 – 0,7 μM/ml).

Clinical-diagnostic significance. Normal activity of AST in blood serum is 0,1-0,45 μM/h∙ml. ALT and AST – indicators of damages of liver parenchyma (especially ALT). ALT activity is; 10 or more times higher than normal during acute hepatitis (viral and toxic); 5-10 times higher than the norm – during acute (viral, alcoholic, drug-induced) hepatitis, acute conditions of chronic active hepatitis and liver tumors; 1,5-5 times above the norm – during all the diseases mentioned above and also during the first week of acute obturation of the common bilary duct.

AST activity changes similarly to that of ALT but is less significance (less frequency of detection and lower rate of activity change). In case of a myocardial infarction AST activity increases by 10-100 times in comparison with the norm. In the initial stage of a myocardial infarction in 24-36 hours it is clearly defined and only on the 3-7th day does the enzymatic activity normalize. Meanwhile changes of ALT are not big/ large / significant .

Pharmacological interference: enzymatic activity can be increased by hepatotoxic and cholestatic medical drugs (see Appendix A).

2. Estimation of the lactate dehydrogenase (LDH) activity in blood serum

Clinical-diagnostic significance. Normal index of LDH: < 7mmol/(h∙l). LDH activity increases in case of myocardial lesion, leukoses, acute viral hepatitis, kidney diseases, sickle-cell disease, thrombocytopenias, infectious mononucleases, and also in cases of progressive muscular dystrophy, all the diseases which proceed to tissue necrosis.

In case of tissue destruction the level of hyperfermentation depends on the intensity and spread of the process. Isozymic tests are more informative. Increase of LDH1activity is observed in case of

25

myocardial infarction, LDH2 and LDH3 – acute leucosis and many other malignant diseases, LDH4 and LDH5 – in case of parenchymatous liver damage. Clear and natural change of LDH1 in case of myocardial infarction, LDH5 – in case of hepatitis provides high organic specificity of these isoforms.

Chemical and pharmacological interference. Increases are caused by analgestics, clofibrate, dicumarin, ethanol, ftoridine, imipramine, methotrexate, narcotic analgesics, nitrofurantoin, quinidine, sulfanilamides and other hepatotoxic medical drugs. Oxalates and urea cause decreases.

3. Estimation of the sorbitoldehydrogenase (SDH) activity in blood serum

Clinical-diagnostic significanceNormal indices: to 5,6 nmole/(s∙l), or to 0,02 μM/(h∙ml). Conside-

rable increase: acute infectious hepatitis (5-10 times higher than norm).

Moderate increase: toxic hepatitis (drug-induced hepatitis, poisoning with hepatotropic poisons, death-caps, alcohol), acute condition of chronic hepatitis, cirrhosis.

Estimation of SDH activity is of great importance for differential diagnostics of hepatocellular and obstructive jaundice. In case of obstructive jaundice, not complicated by inflammatory process SDH is within the bounds of norm and rises sharply in case of acute hepatitis. This index has high reliability and informativity in comparison with other enzymes used for this (alkaline phosphatase, 5-nucleotidase, etc.)

Chemical and pharmacological interference. Enzyme activity is increased by phenothiazines, borates, cysteine, glutathione, ethylene diamine tetraacetate (EDTA), mercury, silver (Ag), cyanides, monoiodine acetate, dimercaptoethanol.

Test questions1 What are the uses of enzymes clinically?2 Name the main rules of change of enzymatic activity in case of a

pathology.

26

3 What enzymes are the most informative in the diagnostics of liver diseases?

4 Give an approximate list of enzymes for the diagnosis of heart diseases.

5 In what cases is there advantages of using the isozymes in diagnostics of diseases in comparison with the general enzyme activity?

6 According to what type does activity of the listed enzymes change in case of tissue damages: a) hyperfermentation; b) hypofermen-tation; c) disfermentation? 1) ALT; 2) AST; 3) alkaline phos-phatase; 4) choline esterase; 5) SDH; 6) ornithine carbamoyl-transferase (OCT); 7) F-1-PA (fructose-1-monophosphate aldo-lase).

7 What congenital disease appears as a result of deficiency or lack of the listed enzymes: 1. Phenylalanine 4-hydroxylases: a) phenyl-ketonuria; b) alkaptonuria; c) tyrosinosis? 2. Glucuronyl transfe-rases: a) nuclear icterus; b) acute porphyria; c) albinism? 3. Glu-cose 6-phosphate dehydrogenases: a) cystinosis; b) glycogenosis; c) favism?

8 What type of metabolism disorders does the listed congenital enzymopathies belong to: 1. Glycogenoses. 2. Disaccharide malabsorption. 3. Niemann-Pick disease. 4. Phenylpyruvic oligo-phrenia. 5. Cystinosis. 6. Mucopolysaccharidosis. 7. Galactose-mia. 8. Favism. 9. Hemophilia. 10. Albinism. 11. Nuclear icterus. 12. Gunter’s disease. 13. Alkaptonuria. 14. Sphingolipidosis. 15. Tyrosinosis: a) of carbohydrate; b) proteins; c) lipids; d) pig-mentary; e) porphyrinic; f) hemostasis?

9 Name physiological causes of increase in activity of alkaline phosphatase of blood serum. Explain it.

10 Name causes of increase in activity of alkaline phosphatase of blood serum in case of cholestasis and bone tumors.

11 In what cases is it expedient to examine the isozymic spectrum of alkaline phosphatase? Give an example of possible alternatives for such examinations.

27

12 In case of which diseases is there observed an increased activity of phosphatase acid?

13 Name the diseases and states, in which increased activity of AST plasma is observed. Name the stages of change of enzymic activity in case of these pathologies.

14 Name the diseases and states, in which increased activity of ALT plasma is observed. Name the stages of change of enzymic activity in case of these pathologies.

15 What is the significance of determining the value of the the Ritis index in diagnostics?

16 Name the possible causes of increase in activity of gamma-glutamyl transpeptidase (GGTP).

17 Name the possible causes of increased activity of LDH and isozymes of LDH in plasma.

18 How does the activity of LDH and isozymes of LDH in blood change in case of: myocardial infarction, lung diseases, tumors.

19 Name the causes of increased activity of creatine kinase (CK) of plasma. Mention the level of enzyme activity in cases of different pathologies.

20 How does the activity of the CK isozymes change in case of: myocardial infarction, stenocardia, stroke, muscular dystrophy.

21 Mention the causes of increased activity of amylase of plasma. Name the level of change in enzyme activity in cases of different pathologies.

22 Explain the cause of increased activity of amylase in case of macroamylasemia.

23 Explain the clinical-diagnostic significance of determining the activity of blood cholinesterase.

24 In case of what pathological states is there increased activity of sorbitoldehydrogenase (SDH) in blood?

25 In case of what pathological states is there increased activity of transamidinase in blood? Mention the level of change in activity of enzyme in case of these pathologies.

28

26 What enzymes in blood serum increases its activity in case of acute viral hepatitis: a) ALT; b) GGTP; c) CK; d) SDH; e) cholin-esterase; f) alkaline phosphatase; g) acid phosphatase.

27 Perform differential enzyme diagnostics in case of acute pancreatitis and abdominal form of myocardial infarction.

28 State the possible changes in CK activity in blood serum during different stages of myocardial infarction.

29 State the terms of the highest informativity of detection of CK, AST, LDH in blood serum in case of myocardial infarction according to the scheme: start of increase, maximum activity, return to norm.

30 Give examples of diseases, for diagnostics of which determination of enzyme activity of red blood cells is applied. Explain your answer.

31 Give examples of diseases, for diagnostics of which determination of enzyme activity in urine is applied. Explain your answer.

32 Name the enzymes, determination of activity of which is applied for diagnostics of nephrology and urology. Give examples.

33 Name the enzymes, determination of activity of which is applied for diagnostics in hematology. Give examples.

34 Name the enzymes, determination of activity of which is applied for diagnostics of diseases of pancreas. Give examples.

35 Name the enzymes, determination of activity of which is applied for diagnostics in oncology. Give examples.

36 Give examples of possible physiological variation in activity of CK, ALT, AST and LDH.

Analysis of case historyІ – p. 270 -15.1; 15.2.

Situational tasks1. A 65-year-old man was admitted to hospital with chest pain

after the intensive physical activity. Features of infarction are not seen in ECG. Dynamics of CK was examined within 72 hours. As a result of carried out laboratory examinations was determined: general activity of CK – 300 units/l, 72 hours later – 40 units/l; CK-MB-fraction – at the

29

beginning – 5 units, 72 hours later no activity was detected. Interpret the received results. What diagnosis can be presumed: 1) myocardial infarction; 2) excessive physical activity; 3) pulmonary infarction; 4) stenocardia? What enzymic tests must be made to make the result more clear: 1) AST; 2) aldolase; 3) CE (cholinesterase); 4) alkaline phosphatase; 5) isozymes of LDH?

2. 24 hours passed after the heart operation of a 69-year-old patient when it was detected that ECG and hemodynamic indices showed the possibility of microinfarction. Laboratory examinations were carried out: creatine phosphokinase (CPK) – 3100 units/l (N-55-370); CPK-MB – 70 units/l (N – up to 6% of general CPK); LDH – 500 units/l (N-120-230). Comment on the received results. What diagnosis can be presumed: 1) myocardial infarction; 2) pulmonary infarction; 3) myocardial damage at surgery; 4) stenocardia?

3. A 65-year-old man was admitted to hospital after two days since chest pain appeared. At laboratory examinations was found out the following: CPK – 20000 units / l (N – 55-370); AST – 300 units/l (N – 5-45); LDH – 650 units/l (N – 120-230). Comment on the received results. Can the diagnosis – myocardial infarction be made? What additional examinations should be made to make the diagnosis more clear?

4. A patient M. was admitted to hospital with high-grade jaundice, complaints about nagging in epigastric area and right hypochondrium, itch, quick getting tired, irritability. At the laboratoty examinations the following was detected: hyperbilirubinemia with mostly increased conjugate bilirubin; thymol test in norm, ALT – moderately increased. What diagno-sis can be presumed: 1) acute hepatitis; 2) obstructive jaundice; 3) hemo-lytic jaundice; 4) Criggler-Najjar syndrome? What tests of enzymes must be made to make the diagnosis more clear: 1) CE; 2) alkaline phosphatase; 3) SDH; 4) aldolase; 5) LDH?

5. A patient N. was admitted to hospital with complaints about retro-sternal pain, sudden weakness, hyperhidrosis, sense of fear, vertigo. At the examination of enzymes the following was detected: activity of AST, LDH – inconsiderably increased. What diagnosis can be presumed: 1) myo-cardial infarction; 2) stroke; 3) pulmonary infarction; 4) stenocardia? What enzymic tests must be made to make the diagnosis more clear: 1) creatine kinase; 2) aldolase; 3) cholinesterase; 4) alkaline phosphatase; 5) isozymes of LDH; 6) isozymes of CK?

30

6. A patient I. was admitted to hospital in poor condition with jaun-dice, weakness, unconscious. At laboratory examinations the following was detected: high-grade bilirubinaemia with mostly increased conjugate bilirubin, activity of ALT – within the bounds of norm, CE – considerably decreased. What diagnosis can be presumed: 1) cirrhosis; 2) acute parenchymatous hepatitis; 3) obstructive jaundice? What examinations are necessary to make the diagnosis more clear: 1) AST; 2) SDH; 3) thymol test; 4) isozymes of LDH?

7. A patient B. was operated on for cholelithiasis in a clinic. As anaes-thetic myorelaxants were used. In the course of operation the patient had cardiac arrest.What diagnosis can be presumed: 1) overdose of narcotics; 2) congenital deficiency of CE; 3) cardiac insufficiency; 4) allergic reaction? What enzymic tests must be made to define the cause of a sudden complication: 1) CE; 2) alkaline phosphatase; 3) AlT; 4) CK; 5) isozymes of LDH?

8. In what type of biological material is enzymic examination the most efficient in case of diseases of: 1) liver; 2) cardiovascular system; 3) lungs; 4) kidneys; 5) digestive system; 6) blood; 7) malignant tumors; 8) nervous system; 9) support apparatus; 10) feminine and masculine genital organs; 11) eyes); 12) buccal cavity; 13) congenital enzymopathy:

1. Serum. 2. Lavage liquid (bronchoalveolar lavage). 3. Urine. 4. Ce-rebrospinal fluid. 5. Serous cavity fluid. 6. Synovial fluid. 7. Saliva. 8. Lacrimal fluid. 9. The contents of the stomach. 10. Duodenal contents. 11. Stool. 12. Blood corpuscles. 13. Punctates of tissues. 14. Semen (sperm), prostatic juice. 15. Discharge of feminine genitals. 16. Amniotic fluid.

9. Match the most informative combination of enzymes for examination of the patients with the diseases of: a) liver; b) blood; c) heart; d) kidneys; e) pancreas; f) support apparatus; g) psychic sphere; h) malignant tumors:

1. Amylase. 2. Uropepsinogen. 3. Lipase. 4. Acid phosphatase. 5. ALT. 6. AST. 7. Sorbitoldehydrogenase. 8. Alkaline phosphatase. 9. Glucose 6-phosphate dehydrogenase. 10. Cholinesterase. 11. Lactate dehydrogenase. 12. Isozymes of lactate dehydrogenase. 13. Tripsin. 14. Catalase. 15. Crea-tine kinase. 16. Fructose 1,6-diphosphate aldolase. 17. Fructose monopho-sphate aldolase. 18. Ceruloplasmin. 19. Carbonic anhydrase. 20. Mono-amine oxidase. 21. Acetylcholinesterase. 22. Hexokinase. 23. Arfinase. 24. Adenosine deaminase. 25. Transamidinase. 26. Urokinase. 27. Leucine

31

aminopeptidase. 28. Isozymes of malate dehydrogenase. 29. Isozymes of alkaline phosphatase. 30. Isozymes of amylase.

LiteratureI – p. 225-230

Lesson 4Topic. Clinical and laboratory diagnosis of breaches in

carbohydrate metabolism

Questions for Preparation1 Breaches in digestion and absorption of carbohydrates: symptoms,

clinical and laboratory diagnostics.2 Diabetes melitus: aetiology, pathogenesis, pathophysiological and

clinical symptoms, diagnostics, treatment and its monitoring. 3 Metabolic complication of diabetes.4 Hyperglycemic states: causes, metabolic breaches, clinical and

laboratory diagnostics. Glucosuria. 5 Hypoglycemic states: causes, metabolic breaches, clinical and

laboratory diagnostics.6 Hypoglycemic syndromes.

Perform and interpret the tests results1 Determination of blood glucose using orthotoluidine method

Method principle: heating acetic acid solution together with orthotoluidine glucose creates the compound of blue-green colour. Intensity of its colour is directly proportional to glucose concentration. All aldohexoses react with orthotoluidine reagent but their contents is so little that it allows to measure only glucose.

Work procedure: Measurement of glucose amount is performed according to the steps presented in the table below.

Reagent Test sample, Control Standard

32

ml sample, ml sample, mlTrichloracetic acid – 3 %Blood serumStandard solution of glucoseH2O

Centrifugate (only into test sample)Orthotoluidine reagent

0.90.1-

-Centrifuge for

10 min at 3000 rpm

0.5

4.5

0.9--

0.1Do not

centrifuge

0.5

4.5

0.9-

0.1

-Do not

centrifuge

0.5

4.5Note: Cover test-tubes with foil. Heat in boiling-water bath for 8 minutes then cool till room temperature. Put into photoelectrical calorimeter at λ=590-650 nm (red and orange light filter) and cuvette thickness 1.0 cm against control sample. Calculation is performed according to the formula:

,

where Ct is glucose concentration in test sample, mg/100 ml (mg %) (coefficient for converting into CI units is 0.0555);Cs is glucose concentration in standard solution, mg %;Et, Es are optical density of test and standard samples respectively.

Clinical and diagnostic value. According to this method glucose concentration in blood is 3.33-5.55 mM/l. Physiological hyperglyce-mia is observed in emotional stresses, consuming of great amount of carbohydrates with food. Pathological hyperglycemias are observed in diseases of endocrine system, diabetes mellitus, tumors of adrenal cortex and hypophysis, hyperfunctioning of thyroid gland, severe dysfunctioning of liver, organic affection of central nervous system. Hypoglycemia is observed at adenomas of pancreatic islets, weak functioning of thyroid gland, adrenal bodies, hypophysis, fastening, hard physical work, overdose of insulin during, breaches in carbohydrate absorption, kidneys diseases that are accompanied by decrease of kidney threshold for glucose.

33

Chemical and pharmacological interference. Glucose level in blood is increased by amphetamine, caffeine, ethionamide, protionamide, substances of morphous action, aspirin, vitamins C and D, clonidine, hemiton, diazoxide, benzohexonium, furosemide, chlortiaside, etc. Glucose level is decreased by isobarine, nicotinic acid, glycerin. 2 Determination of ketone bodies in urine 2.1 The Legal’s test for determining the presence of acetone and acetoacetic acid.

Method principle: In alkaline environment acetone and acetoacetic acid together with sodium nitroprusside gives red colour substance. When concentrated acetic acid is added the complex salt of cherry-red colour is formed.

Work procedure: Two test-tubes are filled with 0.5 ml of urine: the first one is filled with urine of a healthy person (control sample), the second one is filled with urine of a patient suffering from diabetes. In each test-tube 0.5 ml of NaOH (consentrated) solution and 5-7 drops of sodium nitroprusside are added. Red colour is observed in the second test-tube (urine of the patient). The solution is then acidified with several drops of concentrated acetic acid. The colour becomes cherry-red shades. 2.2 The Gerhard’s reaction to acetoacetic acid.

Method principle: Adding of ferric chloride solution into urine results in sediment of phosphates (Fe3PO4). In the presence of acetoacetic acid after adding some extra ferric chloride cherry-red colour appears. Some time later the colouring becomes more pale because of decarboxylation of acetoacetic acid and it is converted into acetone. Speed of the reaction increases greatly with heating.

Work procedure: Two test-tubes are filled with 2 ml of urine (that of a healthy person and of a patient with diabetes), then ferric chloride solution of 10 % is added in drops until phosphates stop forming sediment. The sediment is filtrated. Some more drops of FeCl3 are added to the filtrate resulting to cherry-red colour in the testtube with the patient’s urine.

34

Clinical and diagnostic value. 20-40 mg of ketone bodies is excreted with urine of a healthy person a day. Hyperketonemia and ketonuria are observed in diabetes mellitus, fastening, deficiency of carbohydrates in food, problems with gastrointestinal tract, overproduction of hormones that are antagonistic to insulin (corticosteroids, thyroxine, hormones of hypophysis anterior part, etc.). Decrease of ketone bodies amount is of no clinical significance. In early childhood long standing problems with gastrointestinal tract (toxicosis and dysentery) can lead to ketonemia as a result of chronic fastening and exhaustion. 3 Determination of glucated hemoglobin (HbA1C) and fructosamine in blood

The process of protein glucosing (and hemoglobin too) depends on glucose concentration and takes place during “life period” of proteins. Amount of hemoglobin characterizes average level of glucose during previous 4-8 weeks (providing the life period of erythrocytes does not decrease as it is in case of hemolytic anemia).

Determination of glycated hemoglobin helps to control patients’ state reliably and with greater intervals. In case of latent diabetes mellitus amount of HbA1C is sometimes higher than in case of evident disease. This can be explained by a possible effect of therapy. Increase of HbA1C amount is not connected with hyperglycemia of nervous origin and can be observed at kidney failure, pregnancy and its complications, gynecological diseases, falcular anemia and other illnesses that are accompanied by breaches in carbohydrates exchange.

It is recommended to use determination of HbA1C with screening examination because it is more informative comparing with single measurement of glucose in blood. At the same time it is safer comparing with the method of glycemic curves. Determination of fructosamine amount in blood serum gives information about glucose level only during previous 7-14 days, It can be used while bringing the patients from decompensate diabetes mellitus state when glycol-hemoglobin still remains on a high level. The method gives a possibi-

35

lity to monitor patients’ state. These two methods used with patients suffering from diabetes mellitus give similar results. 4 The oral glucose tolerance test

Method principle: Blood sample is taken from a patient’s finger and glucose concentration is measured. After that a patient is given glucose solution in water (the proportion is 1 g of glucose for 1 kg of body weight). Then during three hours additional blood samples are taken with certain time intervals and the amount of glucose in them is measured using orthotoluidine or glucose oxidation methods. Based on the results a glucose curve is formed where the vertical axis shows glucose amount in mM/L and the horizontal axis shows time in minutes.

It is recommended to take blood samples after 30, 90, 120, 150, 180 minutes. When a person is healthy then in 15 minutes after taking glucose solution the amount of glucose in blood is observed and its maximal level is noted in the period from 30 to 60 minutes. After this the amount starts to decrease. In 120 minutes glucose amount can be even less then the initial one. In 180 minutes the glucose amount in blood usually returns to the normal.

Glycemic curve has three phases. The first phase is caused by the influence of vegetative nervous system when a reflex from mucous membrane in the mouth and stomach is transferred to sympathetic nervous fibers and this leads to increased secretion of adrenalin and disintegration of glycogen in liver. Amount of glucose in blood begins to increase in 10-15 minutes after the starting of the process.

The second phase is characterized by maximal increased which is observed at the 60th minute after the process and normally the glucose amount this time is higher than the initial one by 35-80 %. This phase is caused by glucose absorption in to the blood from intestines.

The third phase is characterized by decrease of glucose amount and normally its level returns to the initial one or close to it in 2.5-3 hours.

36

Figure 1. Types of glucose amount curves: A — diabetes, B — hyperthyroidism, C — norm, D — Addison’s disease or hypothyroidism or hyperinsulinaemia

There are three types of glycemic curves: type I (A) is diabetic. The curve is high and long-lasting, it takes more than 3 hours for it to come back to the initial figures. Besides diabetes mellitus such type of a curve is observed by pheochromocytoma, Cushing’s syndrome, acromegalia, glycocorticoid therapy, diffuse lesion of liver with evident functional failure. In the latter case it is caused by breaches in glucose assimilation.

Type II (B) is irritative. The curve is with high increase and quick decrease. Such curves are typical in hyperthyroidism, glycogenosis (accompanied by hypoglycemia), in case of strong emotional, toxic and infective states, after gastrectomy. They are also observed in liver diseases but in this case they are of no clinical significance because of influence of numerous outer-liver factors.

Type III (D) is torpid. The curve is with low increase. It can happen in two variants: a — insignificant increase and in 3 hours sudden hypoglycemia. Such a curve is observed in insuloma,

37

Addison’s disease, myxedema, intestinal diseases, in case of liver pathology; b — curve increase is insignificant but its decrease is long-lasting, it does not return to norm in 3 hours. Such type of the curve can be observed in cases of liver cirrhosis.

Clinical and diagnostic value. The oral glucose tolerance test method allows to find out hidden forms of diabetes mellitus, breaches in glycogen-forming function of liver and insulin influence of carbohydrate exchange. In diabetes, acromegaly, hyperthyroidism, hepatitis, liver cirrhosis one can observe a sudden increase of glucose amount in blood (up to 22 mM/l) and then its slow decrease.

Test questions1 What is the meaning of “kidney threshold”? Is hyperglycemia

always accompanied by glycosuria? 2 Name the main differences between laboratory tests results in

hypo- and hyperglycemic comas.3 Describe the diagnostics of diabetes mellitus according to the data

of carbohydrate exchange.4 How can you explain the absence of glycosuria if hyperglycemia

is present and exceeds the kidney threshold? 5 What is HbA1C hemoglobin? 6 On what steps of glucose exchange can the connection with

protein and fat exchange appear: a) forming of glucosed phos-phate; b) forming of phosphotriose; c) forming of carbon dioxide residue; d) forming of α-keto-glutaric acid?

7 What factors determine the possibility of excreting glucose with urine: a) glucose concentration in blood; b) intensity of glucose absorption in intestines; c) value of glomerular filtration; d) canal re-absorption?

8 What diseases are accompanied by increase of glucose amount in blood: a) pheochromocytoma; b) insulinoma; c) myxedema; d) Addison-Biermer’s disease?

9 What diseases are accompanied by decrease of glucose amount in blood: a) Cushing’s syndrome; b) hyperthyroidism; c) acromega-ly; d) insulinoma?

38

10 What should be measured on the first day if acute pancreatitis is supposed: a) blood glucose; b) urine glucose; c) blood amylase; d) urine amylase?

11 Name the main criteria of the WHO for diagnosis of diabetes.12 Name the criteria according to which breaches of glucose

tolerance are diagnosed.13 Name the main indications for performing glucose tolerance test?14 Describe the method of glucose tolerance test and interpret the

results.15 Describe the diagnostic meaning if determed glucose in urine

during monitoring of diabetes treatment.16 Describe the clinical and diagnostic meaning of determining

glucose hemoglobin during monitoring of diabetes treatment.17 What laboratory tests are used in monitoring of diabetes

treatment?18 Describe the clinical and diagnostic meaning of determining

fructosamine during monitoring of diabetes treatment.19 Explain the causes of ketoacidosis in case of diabetes. 20 Describe the main principles of testment in case of diabetic

ketoacidosis. 21 What changes in the main features of blood and urine are observed

in diabetic ketoacidosis? 22 Describe the main principles of test in case of hyperosmolaric

non-ketotic hyperglycemia. 23 Explain the possible causes of lactacidaemia in case of diabetes.24 Name the main diagnostic criteria of diabetic nephropathy.25 Describe the changes in lipids metabolism in insulin-dependent

diabetes.26 Describe the changes in lipids metabolism in insulin-independent

diabetes.27 Name the reducing compounds in urine that lead to the positive

result of clinical test.28 Explain the clinical and diagnostic meaning of determining

glucose in spinal fluid.29 Name the main causes of reactive hypoglycemia.

39

30 Name the main causes of fastening hypoglycemia. 31 Describe the clinical symptoms of acute hyperglycemia.32 Describe the main criteria if diagnosing hypoglycemia. 33 Explain the development of hypoglycemia I case of using some

pharmacological substances.34 Explain the causes of possible development of hypoglycemia after

eating some fed state. 35 Explain the potential role of alcohol in development of

hypoglycemia after eating. 36 Describe the laboratory diagnosis of insulinoma. Draw a glycemic

curve typical for this disease and explain it.37 Explain the causes of developing hypoglycemia in case of tumors. 38 Explain the diagnostic meaning of C-peptide in blood serum.39 Name the diseases of endocrine system that are accompanied by

development of hypoglycemia. Explain your answer.40 Describe the changes of biochemical features of blood in case of

hypoglycemic and hyperglycemic coma.41 Explain the development of hyperglycemia in case of

hyperthyroidism.42 Explain the development of hyperglycemia in case of Cushing’s

syndrome. Draw a corresponding glycemic curve.43 Explain the causes of development of steroid diabetes; name the

changes in the results of blood and urine results. 44 Draw a glycemic curve in case of pheochromocytoma. Give your

explanation.45 Draw a glycemic curve in case of acromegaly Give your

explanation46 Explain the causes of hypophysial diabetes. 47 Give examples of hypoglycemia in case of breaches in the process

of digestion and absorption of carbohydrates. 48 Explain the causes of hypoglycemia in case of glycogenosis. Give

your examples.49 Name chemical or pharmacological substances that influence

glucose amount in blood.

40

50 Draw a glycemic curve of diabetic type. Comment on it, and give examples of the typical diseases.

51 Draw a glycemic curve of irritative type. Comment on it, and give examples of the typical diseases.

52 Draw a glycemic curve of torpid type. Comment on it, and give examples of the typical diseases.

Analysis of case historyI – p. 194-209, 11.1-11.8.

Situational problems1. A woman P. is hospitalized in a poor condition. Consciousness is

obscured, adynamia. Skin is dry, eye are deepened. Face cyanosis. Tachycardia. Smell of acetone from the mouth. Tests results: glucose in blood is 20.1 mM/l, in urine is 3.5 %. What diagnosis can be suggested? What additional tests are recommended?

2. While examining of a patient B. it was found out that glucose amount in urine is 0.9 %. Anamnesis is without peculiarities. The results of clinical tests are without pathology. Glycosuria of alimentary and nervous character is denied. Glucose amount in blood is 4.2 mM/l. What diagnosis can be suggested? What is the further tactics of laboratory examination?

3. The blood and urine tests of a patient with insulin-dependent diabetes gave the following results: blood glucose in two hours after breakfast is 18 mM/l, urine glucose is 2 %, glycated hemoglobin is 6.5%. Analyze the results of laboratory tests.

4. The blood and urine tests of a patient with insulin-dependent diabetes gave the following results: blood glucose in two hours after breakfast is 8 mM/l, urine glucose is 0.5 %, glycated hemoglobin is 10.0 %. Analyze the results of laboratory tests.

5. A patient B. with symptoms of exhaustion is hospitalized in poor condition: consciousness is obscured, cold extremities, tachycardia, vomiting, arterial pressure is 90/60, pulse is 110 per minute. Breathing is deep, loud, smell of acetone from the mouth. Laboratory rests of blood: glucose is 38 mM/l, creatinine is 145 μmol/l, urea is 20 mM/l, Na is 130 mM/l, K is 6.0 mM/l, bicarbonate is 5 mM/l, pH is 7.05. Assess the given results. What diagnosis can be suggested? What additional tests are recommended?

41

6. A young man is hospitalized with pains in abdomen, vomiting, nausea, strong thirsty, pain in chest in the heart region. Breathing is fast. Pulse is 130 per minute, blood pressure is 140/70. In the base of the right lung there is slight crepitation, in epigastric area there is insignificant ache after touching. What diagnosis can be suggested: a) myocardial infarction; b) diabetes complicated by ketoacidosis; c) infection in gastrointestinal tract? What tests should be made in order to define the diagnosis and its details?

7. Interpret the results of blood and urine tests of a patient with diabetes (who is ill for 25 years): blood glucose is 30 mM/l glycated hemoglobin is 15 mM/l, Na is 135 mM/l, clearance of creatinine is 60 ml per minute. In urine: glucose is 2 %, protein is 5.6 g/l, ketone bodies (-).

8. A young woman fainted and was hospitalized. Her husband told that during a party the woman had drink several glasses of wine and suddenly lost consciousness. Besides for the last half of the year sudden mood changes and often dizziness were typical for her. She used to lose consciousness several times at the end of a working day. In hospital the woman’s blood was tested and the glucose level was 1.6 mM/l. Glucose was injected intravenously but some time later the woman felt dizzy again. What are the causes of such conditions of the patient? What tests should be made for definition of the diagnosis? Interpret the results of the tests.

9. A woman P. is hospitalized in a poor condition. Consciousness is obscured, adynamia. Skin is dry, eye are deepened. Face cyanosis. Tachycardia. Smell of acetone from the mouth. Tests results: glucose in blood is 20.1 mM/l, in urine is 3.5 %. What diagnosis can be suggested? What additional tests are recommended?

LiteratureI – p. 175-198

Lesson 5Topic. Laboratory investigations and biochemical diagnostics of

breaches in lipids and lipoproteins metabolism

Questions for Preparation1 General characteristics of tryacylglycerol, cholesterol and

phospholipids.

42

2 Classification of fractioning methods and metabolism of lipoproteins.

3 Laboratory research of lipids and lipoproteins metabolism. Result interpretation.

4 Breaches of lipids metabolism (adipose infiltration of liver, obesity, atherosclerosis).

5 Classification, characteristics, clinical and laboratory diagnostics of disliporproteinaemies.

6 Pharmacological correction and monitoring of hyperlipoproteinaemia treatment.

Perform and interpret the test results1. Determination of general cholesterol in blood serum using the Ilk’s method

Method principle: In the presence of acetic anhydride and mixture of acetic and sulphuric acids cholesterol makes compound of green colour. The amount of cholesterol is measured according to the intensity of colour using calorimetry analysis.

Process of work: determination is performed in the succession of steps given in the table.Note: All test-tubes, pipettes and cuvettes must be dry.

Reagent Test sample (ml) Standard sample (ml)Test solution (reagent No 1)Standard solutionBlood serum

2.0

-0.1

2.0

0.1-

Mixed by 10-12 shakes and put into thermostat at t=37°C for 20 minutes.Using photoelectrical calorimeter at λ=630-680 nm and cuvette thickness 5 mm the extinction against water is measured.

Calculation: cholesterol concentration is measured according to the formula

,

where X — amount of cholesterol in the test serum (mg/100 ml)Et — extinction (optical density) of the test sample

43

Es - extinction (optical density) of standard solutionChs - cholesterol concentration in standard solution (180 mg/100 ml)Coefficient for converting into CI units (mM/l) is 0.0258.

Clinical and diagnostic value. Normal concentration of cholesterol in blood serum is 3.0 – 8.8 mM/l. Increase of cholesterol amount in blood (hypercholesterolemia) is observed in the case of atherosclerosis, diabetes, obstructive jaundice, hypothyroidism. Decreasing of cholesterol concentration in blood (hypocholesterol-aemia) is observed by anemia, fasting, tuberculosis, hyperthyroidism, cancer exhaustion, parenchymatous jaundice, fever and while insulin injection.

Chemical and pharmacological interference. Cholesterol amount is increased by androgens, corticosteroids, adrenaline, sulfanilami-des, thiazide diuretics, anticoagulants (fluorides, oxalates), bilirubin. Cholesterol concentration in blood is decreased by asparaginase, chlorpropamide, chlortetracycline, colchicine, haloperidol, kanamy-cine, inhibitors of monoamine oxidase, neomycine. 2. Determination of beta-lipoproteins in blood serum (according to Burstein)

Method principle: The method is based on the ability of β-lipoproteins (low-density lipoprotein) to make sediment in the presence of calcium and heparin. This causes solution turbidity the degree of which is proportional to the amount of β-lipoproteins (β-ЛП).

Process of work: Solution of CaCl2 (0.025M) in the amount of 2 ml is put into a test-tube, 0.2 ml of serum is added. The contents are thoroughly mixed. Then using photoelectrical calorimeter at λ=360-630 nm (red light filter) and cuvette thickness 0.5 cm the extinction (optical density, E1) against distilled water is measured. The solution from the cuvette is put into a test-tube, after that with the help of a micropipette 0.04 ml of 1%-solution of heparin is added. Everything is mixed and exactly in 4 minutes optical density of the solution (E2) is measured under the same conditions.

Extinction difference (E2 – E1) conforms to the optical density which was caused by the amount of β-lipoproteins.

44

Calculation: Amount of β-lipoproteins is measured in units of optical density that is multiplied by 100:

X = (E2 – E1) · 100

Clinical and diagnostic value. Normal concentration of β-li-poproteins is 35-55 units. Increasing of the amount of β-lipoproteins is observed by atherosclerosis, obstructive jaundice, hepatitis, diabetes, obesity, etc. One should define correlated dependence between triacylglycerol, cholesterol and β-lipoproteins. It is observed that both cholesterol and triacylglycerol amounts in plasma increase together with the increase of β-lipoproteins amount.

3 Determination of general phospholipids in blood serum according to the amount of phosphate (Silversmith-Davis method)

Method principle: general concentration of phospholipids is measured according to the amount of lipid phosphorus. Phospholipids are sedated by trichloracetic acid together with blood protein. In the resulted sediment the amount of phosphorus is measured with the help of calorimetry analysis.

Process of work:Reagent Test sample, ml Control sample, ml Standard

sample, ml1 2 3 4

WaterSerumTrichloroacetic acid – 10 %(the first 1.5 ml in drops while shaking the test-tube)

3.00.23.0

---

---

The mixture is left for 1-2 minute, then centrifuged for 5 minutes at 3000 rpm, non-sedated liquid is poured out and then added to sediment. Chloric acid 50-80 % 1.0 - -The mixture is heated in boiling-water bath for 20-30 minutes till the solution loses its colour.

45

1 2 3 4Working standard solutionChloric acid 50-80 %Water

Ammonium molybdate 2.5 %1 % solution of aminonaph-tholsulphonic acid sodium salt

--

Increased to 7 ml

1.01.0

-0.8

Increased to 7 ml

1.01.0

2.00.8

Increased to 7 ml

1.01.0

Everything is mixed, the volume of solution in each test-tube is increased to 10 ml using distilled water.

In 20 minutes with the help of photoelectrical calorimeter at λ=630-690 nm (red light filter) and cuvette thickness 1.0 cm the extinction against control unit is measured.

Calculation: Amount of general phospholipids is measured according to the formula:

,

Et and Es are test and standard extinction0.05 is amount of phosphorus in standard solution, mg/ml0.2 is volume of the tested serum25 is conversion into general phospholipidsCt is concentration of general phospholipids, mg/ml

To convert the result into mM/l it should be multiplied by 0.3229.

Clinical and diagnostic value. Normal amount of general phospholipids in blood serum is 1.5 – 3.6 g/l. Increasing of this amount (hyperphospholipidaemia) is observed by complicated form of diabetes, nephrosis, chronic nephritis, obstructive jaundice, etc. Decreasing of the amount (hypophospholopodaemia) is observed by atherosclerosis, anemia, fever, alimentary dystrophy, liver diseases.

Pharmacological interference. The amount of general phospholipids is increased by adrenalin, estrogens, chlorpromazine. The amount is decreased by asparaginase, acetylsalicylic acid, cholestyramine, clofibrate, ethanol, nicotinic acid, thyroxine.

46

3. Determination of X-lipoprotein in blood Clinical and diagnostic value. Determination of X-lipoprotein

enables to perform differential diagnosis of cholestasis inside and outside liver. Cholestasis is characterized by hypercholesteraemia, decrease of high-density lipoprotein amount and appearance of X-lipoprotein of a special kind.

Test questions1 What main functions do lipids perform in human body?2 What processes are crucial for lipid resorption?3 What ferments take part in hydrolysis of lipids?4 What are the ways of cholesterol moving out of the human body?5 Where does etherification of cholesterol take place? What ferment

participates in this process?6 What are the classes of lipoproteins according to their density?7 What pathological states accompany adipose hepatosis?8 Name methods of hyperlipoproteinaemia diagnosis.9 What is the practical significance of defining the type of

hyperlipoproteinaemia?10 What are the complexes in which endogenic triglycerides

(chylomicrons, low-density, very low-density and high-density lipoproteins) are the parts?

11 What factors influence the amount of cholesterol in blood: a) age; b) gender; c) hormonal status; d) kind of nutrition?

12 What tests are the most informative for diagnosis of breaches in lipids exchange: a) general lipids; b) general cholesterol: c) cholesterol fractions; d) triglycerides?

13 What types of hyperlipoproteinemia are characterized by decreased activity of lipoproteidlipase: 1) I; b) IIa; c) IV; d) V?

14 Where are very low-density lipoproteins formed: a) intestines; b) liver; c) adipose tissue?

15 Name the functions of the main apoproteins of groups A and B.16 Name the functions of the main apoproteins of groups C and E.17 Characterize lipoproteins (a) and lipoproteins (x).18 Explain the role of lipoproteinlipase.

47

19 Show the interconnection between exchange of chylomicrons and very low-density lipoproteins.

20 Explain the role of immediate density lipoproteins and low-density lipoproteins in cholesterol metabolism.

21 Explain the role of lecithin acyltransferase and protein transferring cholesterol ethers in metabolism of this lipid.

22 Explain the role of high-density lipoproteins in lipids metabolism.23 Explain the role of very low-density lipoproteins in lipids

metabolism. 24 Name physiological changes in concentrations of general

cholesterol, cholesterol of low-density lipoproteins and cholesterol of high-density lipoproteins in blood.

25 Name physiological changes in concentrations of triacylglycerol, general cholesterol, high-density lipoproteins/general cholesterol in blood.

26 Explain the concept “atherogenicity coefficient”. Explain its normal measures.

27 How is the amount of cholesterol of low-density lipoproteins measured (in the presence of the following substances: general cholesterol, cholesterol of high-density lipoproteins and triacylglycerol)? Mention the concentration of cholesterol of low-density lipoproteins in plasma that is considered to be extreme.

28 Show and explain electrophoretogram of blood lipoproteins in the norm.

29 Characterize methods for fractioning of blood lipoproteins. 30 Describe general principles of blood test for analyzing lipids. At

what pathological states is determination of lipid metabolism features an obligatory process and in what cases is it recommended?

31 Name changes of lipid metabolism features and clinic symptoms at hyperlipoproteinaemia of type I. Show electrophoretogram of lipoproteins.

32 Name changes of lipid metabolism features and clinic symptoms at hyperlipoproteinaemia of type II a. Show electrophoretogram of lipoproteins.

48

33 Name changes of lipid metabolism features and clinic symptoms at hyperlipoproteinaemia of type II b. Show electrophoretogram of lipoproteins.

34 Explain changes of lipid metabolism features and clinic symptoms at hyperlipoproteinaemia of type III. Show electrophoretogram of lipoproteins.

35 Name changes of lipid metabolism features and clinic symptoms at hyperlipoproteinaemia of type IV. Show electrophoretogram of lipoproteins.

36 Name changes of lipid metabolism features and clinic symptoms at hyperlipoproteinaemia of type V. Show electrophoretogram of lipoproteins.

37 Name possible changes in concentration of cholesterol, triacylglycerol and high-density lipoproteins at obesity.

38 Name possible changes in concentration of cholesterol, triacylglycerol and high-density lipoproteins at overuse of alcohol.

39 Name possible changes in concentration of cholesterol, triacylglycerol and lipoproteins at cholestasis.

40 Explain the possibility of using analysis of apoprotein amount in blood plasma for diagnosis of dislipoproteinaemia.

41 Name possible causes of emerging secondary hyperlipidaemias and changes of lipid exchange features at these diseases.

42 Explain what kinds of hyperlipoproteinaemia are most often accompanied by atherosclerosis. Comment on your answer.

43 Name the main changes in lipid exchange features and clinic symptoms at family hypercholesteraemia.

44 Name the main changes in lipid exchange features and clinic symptoms at the disease of “wide β-stripe”.

45 Name the main changes in lipid exchange features and clinic symptoms at hypobetalipoproteinaemia, Tangier disease, abetalipoproteinaemia.

46 What laboratory tests should be made in order to expose dislipoproteinaemia.

49

47 Give the classification of hyperlipidaemia. Name the peculiarities of interpretation of laboratory tests results for determining the type of hyperlipidaemia and the risk of appearing of atherosclerosis.

48 Explain the examination peculiarities of patients with hyperlipidaemia.

49 Give examples of pharmacological preparations that are used o correct hyperlipidaemia. Explain the mechanisms of their influence.

Analysis of case historyI – p. 255-258, 14.1 – 14.5

Situational problems1. A man of 40. In anamnesis: patient’s parents suffered cardiovascular

diseases. The patient complains about frequent fits of stenocardia. Tests results: blood plasma is transparent; cholesterol amount is 14.4 mM/l, triglyceride (TG) is 1.7 mM/l, cholesterol of high-density lipoproteins is 0.72 mM/l. What tactics should a doctor use? What is the type of hyperlipoproteinaemia?

2. A child of 10 years, suffers periodical pain in abdomen. There is xanthoma on skin. Examination reveal hepatosplenomegalia Blood serum is turbid. Cholesterol amount is 4.3 mM/l, general lipids amount is 18 g/l. What tests should be made and what diagnosis can be supposed?

3. Interpret the results of blood serum tests, define the type of hyper-lipoproteinaemia (HLP). Show electrophoretogram of lipoproteins that conforms to the given type of lipoproteinaemia. Blood serum is transparent, X-lipoprotein (CL) amount is 23 mM/l, triglyceride is 1.4 mM/l, low-density lipoprotein amount is 8 g/l, high-density lipoprotein amount is 1.25 g/l, very low-density lipoprotein amount is 2.0 g/l, chylomicrons amount is 0.2 g/l.

4. Match the results of lipids research in blood serum with types of hyperlipoproteinaemia:

CL, mM/l TGmM/l

Lipoproteins, g/l Type of HLPHigh-density Low-

densityVery low-

densityChylo-microns

Healthy 2.97-8.79 0.59-1.77 1.25-6.5 3-4.5 1.5-2.0 0-0.5No 1 8.0 5.4 1.3 2.8 4.7 0.15 II aNo 2 13.0 2.5 1.25 9.0 4.0 0.2 II bNo 3 23.0 1.4 1.25 8.0 2.0 0.1 IV

50

5. Patient B. with insulin-dependent diabetes, 65 years old, complains about pains in his heart, dizziness, there have appeared xanthomas on his skin recently. The results of blood serum test are: glucose is 10 mM/l, CL amount is 8.0 mM/l, TG amount is 5.4 mM/l, very low-density lipoprotein amount is 4.7 g/l, low-density lipoprotein amount is 2.8 g/l, high-density lipoprotein amount is 1.3 g/l, chylomicrons amount is 0.1 g/l. Blood serum is turbid. After settling a cream-like layer is not formed. Define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to this type of lipoproteinaemia.

6. Interpret the results of blood serum tests, define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to the type of lipoproteinaemia. Blood serum: CL is 7.7 mM/l, TG is 5.2 mM/l, low-density lipoprotein amount is 4 g/l, high-density lipoprotein amount is 6.0 g/l, very low-density lipoprotein amount is 1.5 g/l, chylomicrons amount is 2 g/l. Blood serum is turbid and of milky colour. After settling a cream-like layer was formed, underneath the serum is transparent.

7. Interpret the results of blood serum tests, define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to the type of lipoproteinemia. Blood serum: CL is 42.0 mM/l, TG is 25.2 mM/l, low-density lipoprotein amount is 4 g/l, high-density lipoprotein amount is 5.8 g/l, very low-density lipoprotein amount is 3.8 g/l, chylomicrons amount is 1.7 g/l. Blood serum is of milky colour. After settling a cream-like layer was formed, underneath the serum remains turbid.

8. Patient of 40 years suffers from obesity. After interrogation it is found out that he overused alcohol for a long time. The patient complains about permanent pain in epigastric area. Liver is enlarged by 10 cm. After analysis of blood functional samples serum is found to be turbid. What tests of lipid exchange should be made in this case and why? What results can be expected?

9. A man of 40 complains about permanent pain in his chest, especially during physical exercise. The examination shows xanthomas on his hands and legs. In anamnesis: patient’s father and brother suffered from cardio-vascular diseases. Liver, kidneys and thyroid gland function without chan-ges. Arterial pressure is 170/110. Results of laboratory tests: blood glucose is 4.7 mM/l, CL is 16.8 mM/l, TG is 2.4 mM/l, low-density lipoprotein

51

amount is 14.0 mM/l, high-density lipoprotein amount is 0.85 mM/l. What breach of lipid exchange can be supposed? What is doctor’s further tactics?

10. Patient of 40 is hospitalized with diagnosis of acute pancreatitis that showed itself after drinking too much alcohol. The Patient is obese and smokes. He has been suffering from uretic arthritis for 10 years. Examination results: arterial pressure is 150/100. Blood test: glucose is 7 mM/l, TG is 11.9 mM/l, CL is 6.8 mM/l, uric acid is 0.31 mM/l, amount of cholesterol in very low-density lipoproteins are increased. What diagnosis can be supposed: a) hyperlipoproteinaemia, b) hyperlipidaemia, c) cholesteraemia. Explain your choice. What additional tests can be made? What should be the further tactics of a doctor?

11. A woman of 50 has extra weight, long standing hypertension and numerous xanthomas. In her family anamnesis shows that there are no patients with heart ischemia. The results of laboratory tests: Xl is 25.6 mM/l, TG is 15 mM/l. After electrophoresis of lipoproteins it is found out: Start

+ - Interpret the results of electrophoresis. What breach of lipid exchange

can be supposed? What is the doctor’s further tactics? 12. Interpret the results of blood serum tests, define the type of

hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to the type of lipoproteinaemia. Blood serum: is turbid, Xl is 13.0 mM/l, TG is 2.5 mM/l, low-density lipoprotein amount is 9.5 g/l, high-density lipoprotein amount is 1.25 g/l, very low-density lipoprotein amount is 4.0 g/l, chylomicrons amount is 0.25 g/l.

LiteratureI – p. 231-250

52

Lesson 6Topic. Diagnostic criteria of disturbance of water, sodium,

potassium metabolism. Determination of acid-base balance.

Questions for Preparation1 Distribution and role of water, sodium and potassium.2 Mechanisms of regulation of water-salt metabolism.3 Homeostasis of water and sodium. Laboratory assessment of water

and sodium level.4 Breaches of water-salt metabolism: dehydration, hyperhydration,

hyponatraemia, hypernatraemia (causes, clinical symptoms).5 Determination of blood osmolarity. 6 Homeostasis of potassium. Breaches of potassium metabolism:

hypokalemia, hyperkalemia (causes, clinical symptoms, laboratory diagnostics).

7 Homeostasis of hydrogen ions, its regulation. Blood buffer systems.

8 Breaches in homeostasis of hydrogen ions: acidosis, alkalosis.9 Results interpretation after determining of acid-dace balance.

Clinical and laboratory assessment of hydrogen ions level. 10 Oxygen transport and its breaches.

Perform and interpret the test results1. Determination of sodium and potassium concentration in blood serum using atomic absorption spectrophotometer

Method principle: Atomic absorption spectrophotometry is a kind of absorption spectrum analysis based on measurement of monochromatic spectrum absorption by the atoms of substances that evaporate in fire when atoms come from a lower to a higher energetic level.

A very narrow part of the spectrum is absorbed; it is measured in parts of nanometer and is typical for a given element. In atomic absorption spectrophotometer the source of light is from a special lamp inside which there is hot vapor of the analyzed element. Thus, the source of light radiates only on the spectrum, and this absorption must be tested.

53

Clinical and diagnostic value. Normal amount of sodium in blood serum is 138-217 mM/l. Significant increase or decrease of sodium amount shows that in the process of dehydration a person loses water and salts disproportionally. Hypernatraemia is observed at increased diuresis, limited usage of liquid, hyper function of adrenal cortex (Cushing’s syndrome). Hyponatraemia is observed at limited input of sodium, at permanent losses through kidneys, skin (increased sweating), gastrointestinal tract (while vomiting, diarrhea), water surplus in the body, at nephritis, fever.

Normal amount of potassium in blood serum is 3.8-5.2 mM/l. Hyperkalaemia is observed at acidosis, liver decompensation, overdosage of some medicines. Hypokalaemia is observed at incorrect usage of diuretics, dysfunction strikes of kidney canals, at aldosteronism.

Pharmacological interference. Potassium concentration is increased by antiturmor medicines, heparin, histamine, potassium salt of penicillin, tetracycline, and salt solutions. Potassium concentration is decreased by corticosteroids, diuretics, glucose, glucagon, insulin, licorice extract, salicylates. Excretion of urine is increased by corticosteroids, calcitonin, penicillin, sulphates, diuretics; it is decreased by amiloride, anesthetic drugs, adrenalin, somatotropin.

Sodium concentration in blood serum is increased by androgens, adrenocorticotropic hormone, estrogens, peroral contraceptives, sodium hydrogencarbonate, reserpine. It is decreased by diuretics (tiasidic, furosemide), ammonia chloride, heparin, vasopressin. Excretion of urine is increased by diuretics, calcitonin, dopamine, heparin, tetracycline; it is decreased by corticosteroids, diazoxide, adrenalin.

Test questions1 Name biological role and distribution of water in the body.2 What mechanisms provide stability of water environments and

their composition?

54

3 What organs take part in keeping of water-salt homeostasis? Name the causes of its breaches.

4 Explain the role of sodium in the body; name the causes of breaches in its exchange.

5 Explain the biological role of potassium in the body; name the causes of breaches in its exchange.

6 What hormones regulate sodium and potassium exchange: a) thyroxine; b) insulin; c) aldosterone; d) vasopressin?

7 The level of which elements in blood serum depends on kidneys functioning: a) potassium; b) sodium; c) calcium; d) phosphorus; e) iodine; f) copper?

8 What diseases and states lead to increased level of sodium in plasma: a) hyperaldosteronism; b) kidney failure; c) vomiting and diarrhea; d) hypoaldosteronism; e) pressure syndrome; f) hemo-lytic anemia?

9 What state is characterized by the following clinical symptoms: A. Weakness, muscular hypotonia, languid paralysis, of appetite loss, peristalsis weakness, paralytic ileus, tachycardia, heart enlargement. B. Collapse, bradycardia, abnormal heart rhythms, ventricular capture, ventricular tachycardia: a) increased level of potassium in plasma; b) increased level of sodium in plasma; c) decreased level of phosphorus in plasma; d) decreased level of sodium in plasma; e) decreased level of potassium in plasma; f) increased level of phosphorus in plasma?

10 Explain the level of plasma osmolarity which if increased results in sudden increase of vasopressin concentration on blood. Explain the mechanism of this process.

11 Explain the reaction of osmoreceptors to some changes of plasma osmolarity in case of urea concentration increase in blood.

12 Name the factors that stimulate and inhibit secretion of vasopressin.

13 Explain the regulation mechanism of sodium excretion by kidneys.

14 Name possible causes and clinical symptoms of dehydration. 15 Name possible causes of insufficient sodium in the body.

55

16 Name clinical symptoms and consequences of hyponatraemia.17 Describe clinical parameters and laboratory tests results in

hyponatraemia. 18 Describe clinical parameters and laboratory tests results in

dehydration. 19 Name possible causes and clinical symptoms of hyperhydration. 20 Name clinical symptoms of hypernatraemia. 21 Name the situations when it is recommended to measure sodium

concentration in plasma. Repeat the algorithm of hyponatraemia research.

22 What diagnosis can be suggested if a patient’s state is characterized by hyponatraemia, hypokalaemia, tachycardia, hypotension, failure in peripheral blood circulation, oliguria, decreased skin turgor. Explain your answer.

23 Explain the method principle for determination of sodium and potassium concentration in blood.

24 Explain the principle of measuring osmolarity. Give examples of situations when this parameter should be measured.

25 Name pathological states that may conform to the diagnosis criteria of the syndrome of inadequate vasopressin secretion.

26 Name diagnostic symptoms of the syndrome of vasopressin inadquate secretion.

27 Enumerate the factors that influence sodium excretion in the urine. Name the main clinical symptoms of hypokalaemia.

28 Name the causes and clinical symptoms of hyperkalaemia. 29 Describe the general rules of determining hydrogen ions

concentration. 30 Mention the parameters which are necessary to measure

concentration of bicarbonates. Give the equation that is used to determine this figure.

31 Explain the causes of metabolic acidosis, give examples.32 Explain the mechanism of lactate acidosis. 33 Name the changes of blood biochemical characteristic that

accompany non-respiratory acidosis. 34 Name the causes of respiratory alkalosis.

56

35 Name the changes of arterial blood characteristic that accompany acute respiratory acidosis.

36 Name the changes of arterial blood characteristic that accompany chronic respiratory acidosis.

37 Explain biochemical characteristics and name the causes of non-respiratory alkalosis.

38 Explain biochemical characteristics of acute respiratory alkalosis. 39 Explain biochemical characteristics of chronic respiratory

alkalosis.40 Give the algorithm of results analysis for determining acid-base

balance of blood if the level of [H+] is decreased.41 Give the algorithm of results analysis for determining acid-base

balance of blood if the level of [H+] is increased.42 Give the algorithm of results analysis for determining acid-base

balance of blood if the level of [H+] is normal.43 Name the laboratory tests that are compulsory in case of breaches

in acid-base balance of blood. 44 What is the biological role of hydrogen H+ in the body and how

does any change in pH of biological liquids influence physiological functioning of the body?

45 Explain the meaning of the notions “buffer system” and “buffer capacity”.

46 What systems of the body keep stability of H+ ions?47 Is the examination of buffer systems in blood enaush to get the

idea of acid-base balance state? 48 What is the essence of the mechanism for keeping pH

environment stable with the help of hydrocarbonate, phosphate, hemoglobin, protein buffer systems?

49 What changes in acid-base balance tests can help determine metabolic or respiratory acidosis or alkalosis?

50 What changes in electrolytic state of plasma are observed in metabolic alkalosis and acidosis?

51 What are the causes of respiratory alkalosis? What electrolytic changes accompany it?

57

52 How do laboratory results of acid-base balance (ABB) change if metabolic alkalosis is the cause: a) pH increases; b) pCO2

decreases; c) BB increases; d) BE + increases?53 Why do diuretics support outer-cell metabolic alkalosis: a) they

can decrease outer-cell volume of liquid; b) they stimulate excretion of potassium from a cell; c) they increase chlorine excretion from the body; d) they activate reabsorption of sodium into a cell?

54 How do test results change in case of respiratory alkalosis: a) pH decreases; b) pCO2 decreases sharply; c) BE can be with minus sign; d) SB are a bit decreased or remain unchanged?

55 How do kidneys participate in compensation of metabolic acidosis: a) converting dibasic phosphates into monoacid salts; b) excretion of free organic acids as well as the ones in the form of salts is increased; c) ammoniogenesis is intensified, ammonium chloride excretion is increased; d) ammonium chloride excretion is decreased; e) forming of CO2 in kidneys canals is increased?

56 What are the reasons of respiratory acidosis development: a) decrease of respiratory minute volume; b) unregulated controlled breathing; c) high level of CO2 in exhaled air; d) anions loss?

Analysis of case historyI – p. 36-46; 57-66; 2.1-2.10; 3.1-3.8.

Situational tasks1. A 42-year-old patient, admitted to hospital with complaints

of pains in stomach, nausea, cramps. He has been ill for 10 years. During the last month pains in stomach became stronger, vomiting appeared and in the last 24 hours. During the examination – paleness, malnutrition, xerodermia and xerosis of mucuous tunics.1. What examinations must be performed: a) glucose; b) packed cell volume; c) ABB results; d) plasma osmolarity; e) plasmatic electrolytes; e) enzymes; f) rest nitrogen, urea?

58

2. Estimate the results of performed examinations: glucose content – 4,2 mmlole/l; packed cell volume – 0,61; plasma osmolarity – 315 mosm/l; K content – 2,3 mmol/l, Na – 160 mmol/l, Cl – 66,5 mmol/l; ABB: pH=7,6; рСО2=600 mm of mercury column(mm mc); BB = 69 mmol/l; SB = 38 mmol/l; BE=16 mmol/l; ALT – 0,65 units/l; AST – 0,48 units/l; rest nitrogen – 0,73 g/l; urea – 16,6 mmol/l.

3. What disturbance of water-salt metabolism and ABB was detected: a) respiratory acidosis; b) nonrespiratory acidosis; c) respiratory alkalosis; d) nonrespiratory alkalosis; e) hypokalemic and hypochloremic alkalosis; f) hyperosmolar hyperhydration; g) hyperosmolar dehydration; h) hypo-osmolar dehydration?

4. What is the cause of azotemia?5. What diagnosis can be suggested: a) renal insufficiency;

b) pancreatic diabetes; c) acute cholecystitis; d) pyloric stenosis?6. A patient K., 45 years, admitted to hospital unconscious. Taking into

account the words of relatives, he suffers from pancreatic diabetes. During the last week he complained about weakness, sleepiness, superficial, rapid breathing, temperature 38 °С, AP (atmospheric pressure) 90/50, no smell of acetone.

7. What examinations must be performed in the first place: a) blood glucose; b) glucose and acetone in urine; c) ABB indices; d) hemoglobin; e) packed cell volume; f) enzymes; g) urea, creatinine?

8. Estimate the received results of examinations: content of blood glucose – 30 mmol/l; glucose in urine – 5%; no acetone in urine; hemoglobin – 160 g/l; packed cell volume – 0,55; amylase of plasma – 24 g/l; AST – 0,55 units/l; creatine kinase – 12 units/l; urea – 7,8 mmol/l; kreatinine – 0,120 mmol/l. ABB: pH=7,30; рС02 =35 mm mc; BB = 40 mmol/l; SB=21 mmol/l; BO=6 mmol/l.

9. What additional examinations must be performed: a) bilirubin; b) cholesterol; c) electrolytes of plasma; d) plasma osmolarity? Estimate the received results: bilirubin – 17 μmole/l; cholesterol – 6 mmol/l; K content – 6,2 mmol/l; Na – 160 mmol/l; osmolarity – 345 mosm/l.

10. What type of coma does the patient have: a) hypoosmolar; b) hyper-osmolar; c) hypoglycemic acitodic; d) hyperosmolar hyperglycemic nonketonemic; e) uremic?

11. A patient B., 55 years, admitted to hospital with diagnosis of acute pancreatitis. In past history of the patient there is duodenal ulcer, pyloric stenosis on which his was operated 9 years before. Laboratory findings:

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Hb – 135 g/l; packed cell volume – 0,53; whole protein – 82 g/l; glucose – 17 mmol/l; urea – 18 mmol/l; creatinine – 0,60 mmol/l; ionogram: Na – 159 mmol/l; K – 2,6 mmol/l; Cl – 58 mmol/l. ABB indices: pH=7,56; pCO2= 51 mm mc; BB=55 mmol/l; SB=30 mmol/l; BE=18 mmol/l; plasma osmolarity – 330 mmol/l.

1. Estimate the results of the performed examinations.2. Name the diagnosis for disturbance of water-electrolytic metabolism

and ABB.12. A patient I., 39 years, a miner; 16 years of “dusty service”.

Diagnosis: chronic spasmodic bronchitis. Acute condition of emphysema of lungs at the stage of decompensation. Cor pulmonale. Insufficient blood circulation of the stage III. Fibroradial bronchopneumonia. ABB indices: pH=7,180; p CO2= 101 mm mc; SB = 22,0 mmol/l; AB = 34,1 mmol/l; BB = 51,0 mmol/l. What form of ABB disturbance does the patient have?

13. A patient T., 55 years, a baker. “Dusty service” – 18 years. Diagnosis: acute asthmatic bronchitis. Emphysema of lungs. Bron-chiectases the low left part of lungs. ABB Indices: pH = 7,38; p CO2 = 50,1 mm mc; SB = 24,5 mmol/l; AB = 28,6 mmol/l; BB = 60,5 mmol/l; BE = + 0,8 mmol/l. What type of ABB disturbance can be presumed?

14. A patient P., 32 years. Admitted to hospital with complaints about acute pains in the area of stomach. Dyspeptic phenomena. The tongue is dry, furred. Liver is not enlarged. Belly is blown off, tense, pains accompany palpation. Operation. Diagnosis – obstruction. Mesenteric venous thrombosis. ABB indices: pH = 7,18; p CO2 = 30 mm mc; BB = 28,4 mmol/l; SB = 11,4 mmol/l; AB = 10,1 mmol/l; BE = -18 mmol/l. What kind of ABB disturbance can be suggested?

15. A patient V., 22 years, admitted to hospital with complaints about fever, headache, t = 40,5 °С. Sore throat. Diagnosis – paratonsillar abscess. ABB indices: pH = 7,32; p CO2 = 24,4 mm mc; BB = 34,0 mmol/l; SB = 14,8 mmol/l; AB = 12,2 mmol/l; BE = -13 mmol/l. What form of ABB disturbance can be suggested?

16. A patient T., 37 years, brought to hospital unconscious, with cranial trauma. Tachypnoe. ABB indices: pH = 7,58; pCO2 = 24 mm mc; BB = 55,5 mmol/l; SB = 27 mmol/l; AB = 22 mmol/l; BE = +4 mmol/l.

1. What type of ABB disturbance can be suggested? 2. What additional examinations must be performed, on what purpose: a) glucose content in blood; b) global blood test; c) whole protein and fractions; d) packed cell volume; e) tests of coagulogram; f) electrolytes; g) enzymes?

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17. A patient U., 48 years, brought to hospital from the automobile accident cite with complaints of pains in the area of chest, difficult breathing. On the examination – cyanosis of cutaneous layer covering, mucous tunics, acrocyanosis, rapid breathing, hypopnoe, pains accompany palpation of the right part of the chest. ABB indices: pH = 7,26; p CO2 = 80 mm mc; BB = 55 mmol/l; SB = 27 mmol/l; AB = 35 mmol/l; BE = +3 mmol/l. What type of disturbance of ABB can be suggested?

18. A patient S., 48 years, admitted to hospital in the resuscitation department with the diagnosis of bronchial asthma, asthmatic status. ABB indices: pH = 7,15; p CO2 = 60 mm mc; BB = 37 mmol/l; SB = 18 mmol/l; BO = 8,0 mmol/l; AB = 19,4 mmol/l. What type of ABB disturbance can be suggested?

19. A patient L., 36 years, admitted to hospital after hanging. ABB indices: pH = 7,24; p CO2 = 84 mm mc; BB = 51,5 mmol/l; SB = 27,5 mmol/l; BE = +4,0 mmol/l; AB = 35 mmol/l. What is the type of ABB disturbance?20. A patient O., 54 years, admitted to hospital with the diagnosis of poisoning with acetic acid. ABB indices: pH = 7,01; p CO2 = 26,5 mm mc; BB = 22,4 mmol/l; SB = 8,05 mmol/l; BO = 22 mmol/l. What is the type of ABB disturbance?21. What type of ABB disturbance and in what form it can be observed in the organisms of patients with such data of Sigurd-Andersen’s monogram:а) рН = 7,29; 6) рН = 7,33; в) рН = 7,29;рСО2 = 54 mm mc; рСО2 = 31,5 mm mc; рСО2 = 24 mm mc;ВВ = 47 mmol/l; ВВ = 46 mmol/l; ВВ = 31 mmol/l;ВЕ = 2,4 mmol/l; ВЕ = - 8 mmol/l; ВЕ = 13,7 mmol/l;SВ = 22 mmol/l; SВ = 18 mmol/l; SВ = 13,7 mmol/l;АВ = 25,2 mmol/l. АВ = 16 mmol/l. АВ = 11,3 mmol/l. г) рН = 7,55; д) рН = 7,63; е) рН = 7,45;РСО2 = 60 mm mc; рСО2 = 17 mm mc.; рС02 = 22,7 mm mc;ВВ = 74 mmol/l; В = 50 mmol/l; ВВ == 54,0 mmol/l;SВ = 43 mmol/l; SВ = 24,3 mmol/l; SВ = 23,0 mmol/l;АВ = 49,4 mmol/l; АВ = 17,6 mmol/l; АВ = 16,8 mmol/l;ВЕ = + 19,2 mmol/l. ВЕ = 0,4 mmol/l. ВЕ = 2,0 mmol/l.

LiteratureI – p. 13-56

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Lesson 7Topic: Clinical-laboratory diagnostics of disorders of

hemoproteins, porphyrines and iron metabolism. Clinical-laboratory diagnosis of nucleotides metabolism disorders

Questions for preparation1 Hemoproteins, hemoglobin and hemoglobinopathias. Pathological

derivates of haemoglobin.2 Metabolism of porphyrines, metabolism of regulation. Synthesis

of haem.3 Disorders of porphyrines metabolism: porphyrias, porphyrinurias.4 Metabolism of iron. Pathologies of metabolism.5 Metabolism of purine nucleotides. Sources of urates excretion.6 Metabolism of uric acid. Hyper- and hypouricaemia.7 Disorders of purine nucleotides. Pathogenesis of gout. Pyrimidine

nucleotides metabolism. Syndrome of Lesh-Naykhan. Inherited xanthanuria.

8 Disorder of pyrimidine nucleotides metabolism. Inherited orotoaciduria.

9 Laboratory researches under disorder of nucleotides metabolism. 10 Clinical value of determination of uric acid in blood and urine.11 Biochemical methods of correction of pathology of nucleotides

metabolism.

To perform and interpret the results of experiments1 Qualitative test of Mayzer and Granin by exposing in the

urine the components of porphyrines, porphobilinogen Method principle: porphobilinogen (PBG) reacts with n-

dimethyl-aminobenzaldehyde (DAB) forming a red color substance. Substances which give an analogical reaction with DAB (urobilinogen, indole, skatole and others like that) determing extraction with chloroform, in what PBG does not dissolve.

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Work procedure: in a test tube 2 ml of fresh urine, and 2 ml reagent of Erlikh (2% solution of n-dimethylaminobenzaldehyde in 4n solution of muriatic acid). Cherry-red colouring appears which testifies the presence of porphobilinogen.

For identifying of presence of urobilinogen in urine mixture of urine and reagent with the same amount of chloroform is added.

Appearance of colour in the chloroform understratum testifies the presence of urobilin. If the upper layer is coloured, porphyrines are present in the urine.2 Reznik’s and Fedorov’s semiquantitative method of

determination of coproporphyrines concentration in urine Note. Results of experiments 1-2 fill in the table belowNumber of test tube Coproporphyrine Porphobilinogen

1Method principle: the method is based on extraction of

coproporphyrines in acidic environment with the subsequent irradiation of solution from UV-light. After intensity of fluorescence of upper layer of the liquid coproporphyrines are determined in accordance with the scale.

Procedure of work: add to 1 ml of urine, 1 drop of concentrated acetic acid (before the acidic reaction dip litmus paper) and add 1 ml of ether in the test tube with the grinding cork. Contents of test tube is vigorously shaken for 3-5 min.

After precipitation and division look on fluorescence in the wiper layer, containing the stream of UV-light. Scale of determination of coproporphyrines (CP):- 1 mark (blue fluorescence) – normal maintenance of CP;- 2 marks (barely noticeable rose fluorescence) – insignificant

in-crease of concentration of CP;- 3 marks (clear rose fluorescence) – middle increase of

concentra-tion of CP;- 4 marks (weak red fluorescence) - strong increase of

concentra-tion of CP;- 5 marks (clear red fluorescence) – considerable increase of

con-centration of CP;

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Clinical-diagnostic value. Diseases whith disorders of porphyri-nes metabolism are divide into 2 groups: porphyrias and porphyri-nurias. Porphyria is the group of inherited diseases which rises up as a result of deficit of enzymes for porphyrine synthesis. Porphyrinurias is disorder of metabolism of porphyrines, which rises up repeatedly, as a result of basic disease.

Appearing of coproporphyrines, in urine PBG and other components, of porphyrines is observed in different forms of porphyrias. In hepatic porphyrias urine concentration of PBG and D-ALA is considerably increased; in erythropoetic uroporphyrias (porphyrias of Gyunter) is acutely increased concentration of UPG І and CPG І.

2 Determination of haemoglobin by hemoglobincyanide method

Method principle: in reaction with red blood cells haemoglobin oxidizes to methemiglobin (hemoglobin-ОН) which forms colored cyanohemoglobin color, intensity is proportional to concentration of hemoglobin.

Work procedure: 0,02 ml of blood is poured in a test tube with 5 ml of transforming solution (dilution is in 251 times), mix well. Measure in calometry for 10 min at wave of 540 nm (green colour filter) in the cuvette with the thickness of layer 1 cm against the control test. Standard solution of cyanitehaemoglobin is applied unseparated. Measure experimental test.

The calculation of concentration of haemoglobin using the formula below:

Er

Нb in g% = · Cst ·K· 0,01 Est

Нb is concentration of haemoglobin, g %;Er and Est – extinction of experiment and standard tests;Cst is concentration of cyanidehemoglobin in standard solution, 150 g/l, or 59,75 mg%;K is coefficient of dilution of blood; 0,01 is coefficient, mg% in g/l.

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Clinical-diagnostic value. The normal concentration of haemo-globin: for men – 135-180 g/l, for women – 120-140 g/l. The decree-se of haemoglobin concentration in blood (anaemia) is characteristic for acute bleeding, hypoplastic anaemia, hemolytic anaemia on the stage of hemolytic crisis, observed in the deficit of products of red corpuscles, an insufficiency of producing of haemoglobin as a result of disorders of the enzyme systems of metabolism of porphyrines, insufficient use of iron (iron deficiency anaemia), vitamin В12

(pernicious anaemia), as a result of surplus destruction of red corpuscles and losses of Hb in an organism (at hemolytic anaemias, for example as a result of shortening of life-span of red corpuscles).

Change of volume of plasma (acute bleeding, exicosis and other like discuses) and in increase (hyperhydration) can influence on the index of haemoglobin, but it is errorneous changing (not absolute indexes).

The increase of haemoglobin concentration in blood are observed in erythraemia, cardiac decompensation, myeloproliferative diseases and, as a rule, accompanied by the increase of number of red corpuscles.

For the healthy persons, height above the level of sea (in air plane concentration higher), age influence the concentration of haemoglobin. In new-born concentration of Hb is 160, and in few hours - 195 g/l, to the end of the first year of life - 120 g/l. The low values of haemoglobin for the children of the first year of life testify to physiology anaemia, in early childhood concentration of haemoglobin for the sex doesn’t differ. Premature children have lower indexes comparatively with full-term children.

The decrease of concentration of haemoglobin happens more frequent than the increase.

Pharmacological interference. The decrease of concentration of haemoglobin is observed in using of drugs which provoke development of aplastic anaemia; antineoplastic drugs- miylosan, fluorouracil, sarcolysine, mercaptopurine, cyclophosphan; antibac-terial drugs – levomycetin, penicilline, streptomycine, sulfanil-amides, tetracyclines; analgesics – acteylsalycilic acid, phenacetin;

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psychotropic drugs (aminazine); antipaludian (quinacrine) and such drugs which reduce the level of glucose in blood (bucarban).

4 Determination of methaemoglobin Clinical-diagnostic value of determination of haemoglobin and

its derivates. During conversion of haemoglobin iron from bivalent to trivalent (methemiglobine), and also in haemoglobin binding (except for oxygen), for example, СО (carboxyhaemoglobin appears), cyanides (cyanidehaemoglobin) but in sufficient concentra-tion of hemoglobin in organism there is anoxaemia which can cause a lethal end.

Normal concentration of methemiglobin in blood is lower than 2%.

The presence of methemiglobin for healthy people is explained by its protective function for the organism. It incluse phenol, sulphur hydrogen, acids and cyanides which appear in the organism. Cyanidehemoglobine, which appears, relatively harmless, as fissions in the liver.

The increase of concentration of methaemoglobin (methaemiglo-bineaemia) can have the inherited and acquired character. Inherited methemoglobineaemies are observed at the deficit of methemoglo-binereductase, enzymopathes of red blood cells (symptoms of hemolytic anaemias). Acquired methaemoglobinaemias are: mainly toxic (second), can be of endogenous origin, for example in chronic colitis, malignant tumors, burn illness, for pulmonary patients - in insufficiency of circulation of blood, aplastic anaemias.

Acquired methaemiglobinaemies of exogenous origin is observed by entering into the organism nitro- and aminosubstances, oxidants. Nitrates poisoning occurs by using of well water, vegetable meal which contains surplus of nitrites and nitrates, poisoning substances of fat and aromatic nature by aniline inks. Cyanides get into the organism with the meal of vegetable origin.

Pharmacological interference. Furadonin, novocaine, pilocar-pine, phenacetin, sulfonamides, sulfons, PASA, aterbin, barbiturates, preparations of row of premachine, phenothiazine, aspirin, coal tar, nitrate of cerium, lidocaine, thiocarbazone, methylene blue, antipyrine and some other can cause hemiglobinaemia.

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Carboxyhaemoglobin (HbCO) is highly toxic for organism (in an environment, enriched oxygen in oxygenotherapy oxyhaemoglobin appears again). Surplus formation of carboxyhaemoglobin is observed in poisonings with oxide of carbon (ІІ) СО, which appears as incomplete organic matters.5 Determination of uric acid in the blood serum

Method principle: uric acid reduces phosphor-tungsten reagent with formation of complex of blue color. Intensity of colouring is proportional to the concentration of uric acid.

Procedure: an analysis is conducted in accordance with the table below.

Reagent Testexperim

ental ( ml )

standard (ml)

control (ml)

Distilled waterBlood serum Standard solution of uric acidSulphuric acid (0,35М )Natrium tungstate

4,00,5-

0,250,25

4,0-

0,50,250,25

4,5--

0,250,25

Mix, 10 min storage at 20-250С, centrifugate 10 min at 3000 t/minCentrifugal (only for a experimental test)Solution of natrium carbonate Phosphatic-tungsten reagent

3,0

1,51

3,0

1,51

3,0

1,51

Note. Mix, store for 30 min at 20-250С, measure extinction (Eexp. and Est.) against a control test in a cuvette with the thickness of layer 1 cm at wave length of 500-700 nm (red colour filter)

A calculation is conducted with the formulaEexp• С

Х = Est

Х is a concentration of uric acid, mmole/l;Eexp – extinction of experimental test;Est – extinction of standard test;

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С is a concentration of uric acid in standard solution (0,3 mmol/l).

Clinical-diagnostical value. The concentration of uric acid in blood is labile, related to such factors, as age, sex, use of alcohol, smoking and others like that (etc).

Normal values: men – 0,12-0,38 mmol/l; women – 0,12–0,46 mmol/l.

Hyperuricaemia is observed at: gout, diseases of kidneys (renal failure, polycystosis of kidneys, etc.), syndrome of Lesh–Naykhan; acute growth of level of uric acid is observed after treatment of leucosis with cytotoxic drugs.

Hypouricaemia is observed at Wilson’s disease, some malignant diseases (lymphogranulomatosis, bronchogenic cancer, etc.).

Farmacological interference: intake of diazoxide, diuretics (mercury, thiazide, acetasolamide, chlortalidon, etacrinic acid, furosemid, triamteren), adrenalin, noradrenalin, ethanol, etambutol, pirazinamide, salycilates (in small doses), nicotine acid (in large doses), corticosteroids, some antineoplastic drugs increase concentration of uric acid.

Chemical interference: unreal growth of concentration of uriс acid is caused by substances which influence on a reaction with phosphotungstate - glucose, glutation, cysteine, tyrosine, tryptophan, phenols, ascorbic acid, levodopa, methyldopa, methylurinary acid, caffeine, teophyline; reduces - injection of allopurinol.

Test control questions1 Name the structural features of haemoglobin. What are fractions of

haemoglobin in blood of healthy man? 2 Name the intermediate and initial eventual products of

disassimilation of haemoglobin.3 Describe the inherited disorders of haemoglobin metabolism.4 What pathological conditions are accompanied by formation of

derivates of haemoglobin?5 What are the pathogenesis of different forms of anaemias? 6 By what methods is it possible to define the normal and the

pathological forms of haemoglobin?

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7 To what group of proteins does myoglobin (Мb) belong? Is there Мb in blood of healthy man and is it toxic for organism?

8 What typical changes in urine are discoves in primary and secondary myoglobinurias?

9 Is it possible to find out Мb in blood of patients with myoglobinuria?

10 After what clinical and laboratory tests is it possible to differentiate mio- from haemoglobinuria?

11 How quickly does Мb appear in urine and what is the duration of myoglobinuria?

12 What role has alcohol in appearance of myoglobinuria? 13 Why is it necessary to find out myoglobinuria carry from the

beginning of its manifestation?14 When does Мb appear in urine of a patients with the myocardium

intarction and with what methods it is possible to define it?15 In which biological material we can determine myoglobin: а) in

liquor; b) in urine; c) in red blood cells; d) in serum of blood?16 What means the concept «myoglobinuria»: a) name of disease;

b) syndrome, to the concurrent disease; c) secretion in urine of proteins of muscular tissue?

17 After what physical and chemical properties it is possible to distinguish myoglobin from haemoglobin: a) solubility; b) mole-cular mass; c) size of charge; г) spectral properties; д) a prosthetic group?

18 What typical changes in blood and urine are discovered in myoglobinuria: a) high concentration haemoglobin; b) high leucocytosis; c) increasing of concentration of Мb in blood; d) an increase of concentration of residual nitrogen, urea, creatinine in blood; e) increased activity of blood enzymes of CК, AST, LDH; f) increase of concentration of potassium, phosphate; g) acidosis; h) urine painted in a red color?

19 What complications cause appearance of myoglobin in urine: a) cystitis; b) acute renal failure; c) clottages; г) muscular necrosis; д) paresis; е) paralysis?

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20 After what tests it is possible to distinguish myoglobinuria from hemoglobinuria: a) after colouring of blood serum; b) at times appearances of Мb in urine from a moment of disease; c) after concentration of CК in blood; d) after concentration of hemosiderine in urine?

21 What laboratory methods identify Мb: a) by the method of salting-out; b) by the method of electrophoresis; c) by the method of dialysis; d) by a immunoenzyme method; e) by the method of gel filtration; е) by the methods of chromatography?

22 In what form do porphyrines appear in nature, what metals and organic substances form active connections with?

23 Schematically represent synthesis of haem. Is there connection between the synthesis of porphyrines and haem?

24 What porphyrines are educed from urine, faeces, blood and what its origin? On what principle do they differentiate porphyrines?

25 What clinical classification of disorders of porphyrine metabolism do you know? What diseases are included in the group of erythropoetic and hepatic porphyrias?

26 Is urine always coloured for patients with acute intermittent porphyria (AIP)?

27 With what violation of porphyrines metabolism is it necessary to differentiate AIP?

28 What basic symptoms are typical for urocoproporphyrias?29 After what pathogenic signs are some violations of exchange of

porphyrines taken to porphyrinurias?30 What toxic compounds cause disorder of porphyrine metabolism?31 What proteins consist of porphyrines: a) myoglobin; b) catalase;

c) haemoglobin; d) peroxidase; e) haptoglobin; f) cytochrome с?32 What porphyrines and its isomers do they determine in blood and

urines of patients with suspicion on violation of porphyrine metabolism: а) protoporphyrine ІХ; b) coproporphyrine I; c) coproporphyrine III; d) uroporphyrine I; i) uroporphyrine ІІІ; f) protoporphyrine IX?

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33 What properties of porphyrines do they use in laboratory diagnostics: a) ability to absorbe light in the area of Soreta; b) a sensitiveness to the sun radiation; c) dependence of solu-bility of porphyrines from the value of рН; г) stability to high temperatures; д) solubility in ethylacetate, chloroform; е) solu-bility in water?

34 What precursors of porphyrines have a diagnostic value: a) amber acid; b) δ-aminolevulinic acid (D-ALA); c) porphobilinogen (PBG); d) β-ketoadipinic acid?

35 To which form of porphyrias it is possible to take such indexes: child's age, enlarged spleen, clinica hemolythic anaemia, ulcer, scars, erythema of skin covers, hyper sensitiveness to the sun radiation, leucocytosis; increased temperature. Urine is coloured due to the presence of uroporphyrine I: a) uroporphyria (illness of Gyunter); b) hepatic porphyria; c) erythropoetic porphyria; г) cop-roprootoporphyria?

36 What porphyrines and its precursors are determined for patients with erythropoetic and hepatic porphyrias in urine, erythrocytes and faeces:1) in urine: a) uroporphyrines I and III; b) coproporphyrines I and ІІІ; c) PBG, D-ALA.2) in a faeces: a) coproporphyrine I and III; b) uroporphyrines I and ІІІ; in) protoporphyrine ІХ; d) D-ALA, PBG; 3) in red blood cells: a) uroporphyrines I and III; b) copropor-phyrines I and III; c) protoporphyrine IX; г) PBG, D-ALA?

37 What basic symptoms are typical for patients with erythropoetic copro- and protoporphyria: a) urine is red in color; b) haemolysis of red blood cells; c) youth age; d) hypochromic anaemia; e) hyper sensitivity of skin covers to the sun radiation; f) an increase of amount of proto- and coproporphyrines in red blood cells?

38 What factors provoke acute intermittent porphyria: а) pregnancy; b) barbiturates; c) sulpha drugs; d) belaspon; e) antibiotics; f) valo-cardin; g) streptocide; h) analgin; i) teophedrine; j) heparin?

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39 Increase of concentration of what porphyrines (in urine) is typical for the group of hepatic porphyrias: a) coproporphyrine III; b) uro-porphyrine III; c) uroporphyrine I; d) protoporphyrine IX; e) PBG and D-ALA; е) coproporphyrine I?

40 What clinical symptoms and laboratory tests are typical for patients with late skin porphyria: a) typicae anamnesis of the use of alcohol; b) the symptoms of chronic hepatitis; c) rose or orange colouring of urine; d) increase of concentration of protoporphyrine IX in blood; e) superficial traumas of skin covers; f) high concentrations of PBG and D-ALA; g) considerable increase of uroporphyrine III; h) increase of coproporphyrine I?

41 On what basic sign do they distinguish porphyrinurias from porphyrias: a) on age; b) after anamnesis; c) after colouring of urine; d) after high concentration of coproporphyrine III in urine; e) after low concentration of uroporphyrine III in urine; f) after presence of PBG in urine?

42 What diseases can be attributed to the group of porphyrinurias:а) chronic hepatitis; b) cirrhosis; d) infectious hepatitis; e) tumors of liver; д) hypochromic anaemias; е) intoxications by zinc, plumbum, СО, hydrogen sulfide, chlorinated hydrocarbons?

43 Fill in the table with such structure (for hepatic porphyrias):Name of

porphyrias Metabolits

urine blood faeces44 Compare the change of biochemical indexes at innate

erythropoetic porphyrias and in acute intermitter porphyrias.45 Compare the change of biochemical indexes in mosaic and late

porphyrias of skin.46 Describe the change of biochemical indexes in toxic prophyria.47 Describe disorder of metabolism in organs and systems of

organism in hemochromatosis. 48 Describe the dynamic condition of iron deficiency of blood

(transferrin, ferritin) and screening test for the purpose of prophylaxis.

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49 By using biochemical indexes, it is possible to differentiate symptomatic porphyrinurias from chronic hepatitis of skin hepatic porphyrias?

50 Name factors which can provoke the acute attacks of porphyrias. How do the indexes of blood and urine change?

51 Describe reasons of origin of porphyrinurias. What biochemical tests can be used for its diagnostics?

52 Describe the mechanisms of absorption of iron in GIT and its migration in an organism.

53 Describe diagnostic tests for determination of concentration of iron in an organism.

54 Describe iron binding ability of plasma.55 Give description of plasma ferritin.56 How do metabolic processes change in an organism in excess of

iron?57 How do metabolic processes change in an organism deficiency of

iron?58 Describe the changes of metabolism in inherited (primary)

chromatosis.59 Name a disease, where determination of uric acid has a diagnostic

value to a certain extent: a) chronic leucosis; b) pneumonia; c) burns; d) erythremias; e) hemolytic anaemias; f) hepatitis; g) poisoning with land; h) diseases of kidneys; i) progressive muscle atrophy; j) gout.

60 Point the chart of forming of urate pool in organism.61 During what concentration of uric acid in blood will there be a

tendency to formation of sodium urates: а) 0,12 μmole/l; b) 0,10 μmole/l; c) 0,38 μmole/l; d) 0,46 μmole/l; д) 0,15 μmole/l?

62 What is the principle of method of determination of uric acid in blood and urine?

63 Point factors which influence on the level of uric acid in blood.64 What substances are end products of metabolism of uric acid in

intestine: a) ammonium; b) carbon dioxide; c) hypoxanthine; d) urates; e) indican?

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65 What processes takes place with wrates in kidneys: a) filtration; b) absorption; c) secretion; d) reabsorption.

66 In what diseases and why there is an increase of concentration of uric acid in blood serum?

67 Explain reasons of hyperuricaemia.68 What pathological conditions and why are referred to as the group

of diseases under the name of "secondary gout"?69 In what diseases decline of concentration of uric acid in blood is

observed?70 In what pathological conditions hyperuricaemia is accompanied

by hyperuricuria? Give explanation.71 Explain reason of increase of excretion of uric acid with urine at

lung-fever, resolution of extravasates, considerable burns.72 Give examples of diseases at which excretion of uric acid

decreases.73 What factors must be taken into account during interpretation of

results the determine the level of uric acid in blood?74 Name principal reasons of hyperuricaemia.75 One of reasons of hyperuricaemia is chronic renal failure. Is the

use of determination of concentration of uric acid in blood possible for early diagnostics of this disease? Explain an answer.

76 Explain the role of determination of concentration of urates in the blood serum in diagnostics of gout.

77 What laboratory researches are provided for diagnosis of gout next to determination of concentration of urates in blood?

78 Explain what measures are used for the correction of hyperuricaemia?

79 Explain the mechanism of influencing of allopurinol on the level of uric acid in blood.

80 Explain the mechanism of influence of diuretics on the level of uric acid in blood.

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81 For the correction of hyperuricaemia allopurinol is used. Mechanism of its action on hyperuricaemia consists in: a) increase of excretion of uric acid with urine; b) increase of diuresis; c) inhibition of xanthinoxidase; d) diminishing of formation of uric acid; e) diminishing of formation of hypoxanthine.

82 For the correction of hyperuricaemia diuretics are used. Mechanism of its action on hyperuricaemia consists in: a) increase of excretion of uric acid with urine; b) increase of diuresis; c) inhibition xanthinoxidase; d) diminishing of formation of uric acid; e) diminishing of formation of hypoxanthine.

83 Is it possible on the basis of hyperuricaemia to diagnose a gout? Explain an answer.

84 Mark laboratory and clinical indices with which gout is diagnosed.

85 What changes in the analysis of blood and urine (in relation to the products of exchange of nucleotides) will take place at using of allopurinol for the correction of gout.

86 Explain why there is hyperuricaemia at the inherited deficiency of glucose-6-phosphatase.

87 Name principal reasons of development of Lesh-Nayhen synd-rome. What changes of indices in blood and urine are observed at this pathology?

88 Name principal reasons of hypouricaemia. Give examples in diseases at which hypouricaemia is observed.

89 What factors does formation of uric acid in an organism depend on? What are the indices of physiological rippling of concen-tration of uric acid in blood. Name factors which influence on it.

90 What pathological processes in an organism can cause secondary hyperuricaemia? Explain an answer.

91 What are the principal reasons of development of inherited xanthinuria. What changes of indices of exchange of purines in blood and urine are observed at this pathology?

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92 What are the reasons of development of inherited orotoaciduria. What changes of indices of exchange of purines and pyrimidines in blood and urine are observed at this pathology? Is this test used for confirmation of diagnosis?

93 With what diseases is it necessary to differentiate gout? What tests for this purpose can be used?

94 Name pharmacological preparations which increase secretion of uric acid from an organism, explain the mechanism of its action.

95 Explain reasons of difference in the concentration of uric acid in blood and plasma.

96 Explain a mechanism of use of uridine for the correction of inherited orotoaciduria.

Analysis of case history I - P. 295, 299, №17.1, 17.2.

I - P. 305. - №18.1.

Situation tasks1 Patient of 54 years. Pensioner, was a pilot in the past. Last years

worked with ethyl petrol. From this time began to notice pigmentation of hands, scars. Periodically blisters appear on the opened parts of trunk, extremities. Liver is enlarged on 10 cm. Disorders of protein-synthetic function of liver is marked. General protein - 100 g/l, albumins - 40%, globulins - 60%. Iron in plasma of is reduced to 50%. Urine is of rose colour. Coproporphyrines - 222 mcg/g of creatinine. 1 What diagnosis can be assumed? 2 What additional researches are needed to be done? 3 With what diseases is it necessary to differentiate this disease?

2 Patient 40 years. A driver. In anamnesis abused alcohol. Grumbles about dull pains in right hypochondrium. On the surface of skin covers is scratch, pigmentation, appearance of which the patient can not explain. In urine a red pigment appears periodically. Liver is enlarged on 7 cm. 1 What diagnosis can be assumed? 2 What researches are needed to be conducted? What information will confirm the assumed diagnosis?

3 A 31 years illed patient. Two years ago noticed darkening of skin. On forehead, checks gray dark blue spots appeared. Pigmentation spread on the trunk. Laboratory tests (glucose, bilirubin, Nа, K, Ca) are without changes. Liver is enlarged. A general analysis of blood is without deviations from

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normal. Concentration of coproporphyrines III is increased in two times. 1 What diagnosis can be assumed? 2 What additional researches must be done? What diseases is it necessary to differentiate this illness with?

4 Patient of 51 years old. Complaints about permanent dull pains in epigastrium, weakness, emaciation, bad sleep, pouring out on the surface of skin of person, neck, hands as blisters. In anamnesis- abuse of alcohol. First noticed such pouring out a year ago. Acute during spring and summer. On inspection of the skin of the hands, neck, is old scars, pigmental spots, blisters. Liver is enlarged on 5 cm. Glucose, bilirubin, cholesterol - is normal. General protein - 90 g/l, hypoalbuminaemia (47%), hyper-β- and γ-globulinaemia. Urine is of red color. Sediment is without changes. Copro-porphyrines - 717 μg/day. Uroporphrinogen - 80 μg/day. Concentration of urobilin is considerably increase. What diagnosis can be assumed? What laboratory indexes confirmed diagnosis this?

5 Patient of 33 years old, have been ill for 11 years. Periodically visit the doctor with complaints about acute pains in the stomach. Operated three times. Diagnosis ulcer, pancreatitis, cholecysitis. 11 years from the onset of disease after the attacks of pains in the stomach was found out that urine, is of red color. What diagnosis can be assumed? What researches is it necessary to do for confirmation of this diagnosis?

6 Mr. Н. has been ill for 11 years and was hospitalized with diagnosis of hemolytic anaemia. From childhood pallor, rapid fatigue, was marked. Twice parents noticed appearance of icterity of skin covers and scleras. In the analysis of blood: haemoglobin - 63 g/l; red blood cells - 2,3·1012/L; coloured index - 0,8; thrombocytes - 291·109/L; leucocytes - 4,1·109/L. In a formula: е - 1 %; mc - 2%; y - 1 %; r- 2%; s - 29%; lp - 61 %; - 4%. Hypochromia, anisocytosis, normoblasts 2:100, target-like red bllod cells happen for 2-3 in the field of sight. Erythrocyte sedimentation rate (ESR) - 30 mm/hour.1 What diagnosis can be assumed: a) illness of Shenleyn-Genokh; b) eryth-

rocyte enzymepathia; c) hemoglobinosis 5; г) target-like hemoglobino-pathy?

2 What additional researches can be conducted in: a) determining of concentration of НbF; b) electrophoresis of haemoglobin; c) conducting of test on sickle of erythrocytes; г) research of marrow?

7 Patient С. 32 y. During loading of transport fall down. After liberation felt indisposition, pains in right extremity. Did not visit the doctors and went home to sleep. In the morning woke up with feeling of numbness of extremity, sharp pains. Extremity - was sharply swollen, on palpation.

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Hospitalized into department of artificial bud. A catheter is used to called which urine is of color. In the urine by the method of elctrophoresis myoglobin is determined. Before hospitalization the clinical picture of acute renal failure was marked in the department. 12 ham analysis was done. What diagnosis is your diagnosis?

8 For a man 60 years during providing of biochemical analysis of blood was discovered hyperuricaemia (0,50 mmole/l). What is probability of development of gout for him. What recommendations of correction of level of uric acid can be offered to the patient?

9 Patient A was hospitalized in a hospital with the attack of kidney colic. During the last years he used an alcohol almost round-the-clock. The analysis of blood found out hyperuricaemia (0,80 mmole/l). Explain the mechanism of origin of hyperuricaemia and kidney colic. Is it possible to diagnose gout? What additional laboratory tests must be provided for clarification of diagnosis?

LiteratureI – p. 254 -260, 277-286.

Lesson 8Theme. Clinical-laboratory diagnostics of hypothalamus,

hypophysis, adrenal and sexual glands disorders

Questions for preparation1 General description of hormones of anterior and posterior lobes of

hypophysis, adrenal and sexual glands.2 Laboratory diagnostics of disorders of functions of pituitary gland.3 Methods and diagnostic value for determination of steroid protuc

of urine.4 Laboratory tests for the exposure of hypo- and hyperfunction of

adrenal glands.5 Laboratory researches for disorder of functions of sexual glands.

6 The use of radioimmunoassay for determination of concentration of hormones.

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To execute and interpret the results of experiments 1 Quantitative and qualitative determination of 17-ketosteroids in urine

Normal values: - for men – 27,7-79,7 μmol/day;- for women – 17,4-55,4 μmol/day.

Clinical-diagnostical value. The increase of level of 17-Ketosteroids (KS) is observed at hyperplasmia, adenoma, cancer of adrenal glands which is manifestated with virilization; tumours of testicle, interstitial–cellular tumours, luteocytic tumour of testicle; at the hypersecretion of glucocorticiod hormones (Cushing’s synd-rome). The increase of level of 17-Ketosteroids causes hard stress.

The decreace of level of 17-KS is observed at Addison's disease illness, hypothyroesis, exhaustion, hypopituitarism, secondary hypogonadism for women.

For fine endocrinology diagnostics it is better to determine the fractions of 17-KS with method of thin-layer gel filtration.

Pharmacological interference. Meprombat, librium, elenium, chlorpromazin, spironolactone, penicillin (i/v in large doses), erythromycin, corticotrophin, gonadotrophins, testosterone increace the level of 17-KS in urine, reduce – estrogens, oral contraceptives, morphine.

2 Quantitative determination of 11-corticosteroids in plasma of blood

Normal values: 140-230 nmole/l (5-8 μg in 100 ml).Clinical-diagnostical value. Any acute disease can be reason for

increase of secretion of 11-KS, and also nervously emotional and physical tension.. The proof for increase of level of 11-KS is observed at illness of Itsenko-cushing, the adenoma and cancer of adrenal glands, hard hypertension, acromegaly, thyrotoxicosis, obesity, pregnancy.

The decreace of secretion of 11-KS is observed at hypocorticism (Addison’s disease, adrenogenital syndrome), hypothyrosis, hypopituitarism, at the protracted steroid therapy.

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Pharmacological interference. The increace of level of 11-KS: colchicin, glycosides of digitalis, erythromycin, vitamin K, meprobamat, spironolacton. Decreace the level of 11-KS; cortico-steroids and estrogens, morphine, oral contraceptives.3 Radioimmunoassay of concentration of hormones is in blood

The method of RIA is based on the reaction of cooperative antigen (AG) - antibody (АB). An antigen is hormone concentration of which it is determined. Antibodies are produced from blood of laboratory animals to which time is set do the injections of the proper hormone. In RIA a radio-active mark is used, and it is entered in one of components of reaction (АG or АB). Using of radio-active mark enables to determine the very low concentrations of substances (picogram).

For determination of concentration of hormone (AG) in blood of patient we can use: blood serum which contains AG (hormone), to which a complex АG *-АB is added, where АG* is the radio-active marked hormone. After bringing in the blood serum of certain amount of complex AG*-AB there will be replacement of АG* in a complex АG*- АB on АG (depending on the concentration of AB in the blood serum) and a dynamic equilibrium will be set between the components of reactionary mixture. The amount of free АG* after reaction will be directly proportional to the concentration of hormone (AG) in the blood serum. After canceling for the division of two marks composed of AG*-AB and AB* adsorption methods, methods of the fractious besieging and division are used.

On the eventual stage radio-activity of solution or sediment is determined. A calculation is conducted after a calibrate curve which is built as a result of determination of the known concentrations of АG in reactionary mixtures.

In our time most widely RIA is used in endocrinology diagnostics for determination: general thyroxine, free thyroxine, triiodthyronine, thyrotrophic hormone, thirosinconnection globulin, thymoglobulin, title of antibodies to thymoglobulin, insulin, level of ACTH, glucocorticoids, parathyrine and to thyrocalcitonin.

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The radioimmune methods of determination of hormones of hypophysis are inculcated in clinical practice: somatotropin, folitropin, luteotropin, mammotropin, hypophamine and other

To the test control questions1 Explain principles of regulation of endocrine glands activity?2 Name hormones of cortical and medullar parts of adrenal glands,

explain its biological role?3 What clinical-laboratory description of hypofunction of adrenal

glands?4 What diseases and syndromes arise up as a result of hyperfunction

of adrenal glands; their clinical-laboratory picture?5 Name sexual hormones; describe their classification, biological

role.6 What methods are used in our time for determination of

concentration of hormones in the blood serum and urine?7 Mark, the factors which must me taken into account at

determination of catecholamines: a) use of coffee, caffeine; b) use of X-ray contrast substances; c) acceptance of acetylsalycilic, nicotine acids?

8 At what diseases concentration of glucocorticoids in plasma of blood is increased: a) Cushing’s disease; b) pheochromocytoma; c) myxedema; г) rachitis?

9 What diseases are characterized by decreasing of concentration of 17-OKS in blood serum: a) adenoma of cortex of adrenal glands; b) cancer of cortex of adrenal glands; c) hyperplasia of cortex of adrenal glands?

10 For what disease increase of excretion of catecholamines with urine is a specific test: a) hypertensive illness; b) pheo-chromocytoma; c) bronchial asthma?

11 Explain the mechanism of action, regulation of secretion and metabolic effects of growth hormone.

12 Explain the mechanism of action, regulation of secretion and metabolic effects of mammotropin and thyrotrophic hormone (ТТH).

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13 Explain the mechanism of action, regulation of secretion and metabolic effects of gonadotropins.

14 Explain the mechanism of action, regulation of secretion and metabolic effects of adrenocorticotrophic hormone (ACTH).

15 Explain principle of method of radioimmunoassay determination of concentration of hormones in blood.

16 Explain essence of the combined (boluse) test of determination of function of hypophysis. Give examples for interpretation of results of test.

17 Explain procedure of providing the combined (bolus) test of determination of function of hypophysis. Name contraindication for conducting these tests?

18 Name principal reasons for origin of hypopituitarism.19 Explain, on basis of what clinical symptoms we can provide tests

for the exposure of functional activity of hypophysis.20 Name the pathological conditions at which the basic clinical signs

of hypopituitarism are manifested21 Name laboratory researches which are used for determination of

status of growth hormone (STH). Explain essence of these tests.22 Can we use determining of concentration of growth hormone in

blood serum for research of intensity of its secretion?23 What test is used for determination of hyperproduction of growth

hormone? Explain its essence. Give an example of interpretation of results.

24 What tests, except for the exposure of tolerance to glucose, are used for determination of hyperproduction of growth hormone and estimation reactions of patient on treatment?

25 What changes in the biochemical indexes of blood and urine do take a place at?

26 What clinical manifestations of hyper production of (STH) are observed for patients with acromegaly?

27 Name principal reasons and mechanisms of origin and clinical symptoms of hypermammotropinaemia.

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28 Point principal reasons of origin of diabetes insipid. Explain, with what diseases it is necessary to differentiate diabetes insipid? What tests for this purpose can be used?

29 Explain what common features and differences you find in the analysis of urine at primary polydypsia and diabetes insipid.

30 Explain the method of conducting of water deprivation test. Make an example of interpretation of results.

31 Mark an algorithm of inspections of patient with polyuria.32 Explain essence of using of hypertensive solution of sodium

chloride at the ambiguous results of water deprivation test.33 How does the concentration of vasopressin change in blood serum

at primary polydipsia after injection of hypertensive solution of sodium chloride? Explain an answer.

34 How does the concentration of vasopressin change in blood serum at nephrogen and cranial diabetes insipid after introduction of hypertensive solution of sodium chloride? Explain an answer.

35 Mark the basic metabolic effects of glucocorticoids?36 Explain functioning of the rennin-angiotensine system. Name

factors which regulate the secretion of aldosterone.37 Mark clinicae diagnostic value of determination of 11-

corticosteriods and 17-ketosteroids in urine. Name factors which will influence on these indexes.

38 What factors must be taken into account at tests of blood for determination of concentration of hydrocortisone?

39 Name tests which are used for early diagnostics of hyperfunction of adrenal glands?

40 Name obligatory and additional researches of blood and urine, which are provided at diseases of hypothalamic-hypophysis system.

41 Explain essence of pharmacological tests which are appointed at acromegaly for the exposure of active phase.

42 Explain what changes in the protein spectrum of blood take a place at acromegaly.

43 Name principal reasons of origin, clinical symptoms, and laboratory diagnostics of Addison’s disease.

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44 Name obligatory and additional researches of urine and blood, which must be appointed for diagnostics of diseases of adrenal glands.

45 Explain purpose of the prolonged test with synacten on determining adrenal glands deficiency, interpret results.

46 Explain purpose of test with synacten on the exposure of adrenal glands deficiency, interpret results.

47 What laboratory researches are provided for differential diagnostics of primary and secondary deficiency of adrenal glands? Explain interpretation of results.

48 Explain, what changes in the analysis of blood and urine are observed at Cushing’s disease and Cushing’s syndrome.

49 Explain purpose of pharmacological tests which are provided for differential diagnostics of Cushing’s disease and Cushing’s syndrome. Give examples of interpretation of results.

50 What screening tests must be appointed for the exposure of Cushing’s syndrome for patients with a kushingoid kind? How to interpret their result?

51 Explain purpose of screening tests for diagnostics of hyper production of glucocorticoids, interpret their results.

52 Explain Clinical-diagnostic value and of test with dexamethazone, interpret a result.

53 Name reasons, clinical symptoms and laboratory diagnostics of Konn’s syndrome.

54 What tests are used for diagnostics of the latent forms of primary aldosteronism? Explain their purpose and interpret a result.

55 What screening tests are used at suspicion on the Konn’s syndrome.

56 What laboratory researches do they provide for differential diagnostics of primary and secondary aldosteronism? How do they interpret results?

57 What changes in the analysis of blood and urine do allow suspecting the presence of primary aldosteronism? What tests must be conducted for an exception or confirmation of diagnosis? How can we interpret the results of laboratory researches?

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58 What pathological conditions can be accompanied with secondary hyperaldosteronism? Explain an answer.

59 How to interpret the result of determination of concentration of aldosteron in blood depending on position of patient’s organism for differential diagnostics of Konn’s syndrome, which is caused by the tumor of adrenal glands or their hyperplasia.

60 At what clinical displays can we provide laboratory research in the presence of pheochromocytoma? What screening tests are used here?

61 Explain essence of test with pentolinium for determining of pheochromocytoma. Interpret the result of laboratory researches.

62 What changes in the biochemical analysis of blood and urine take a place at pheochromocytoma.

63 Name pharmacological tests which are appointed for determining of pheochromocytoma. What is its essence? How results are interpreted?

64 Name reasons of development and change of hormonal background in blood of patients on primary and secondary hypogonadism.

65 Explain essence of test with chorion gonad tropic hormone for diagnostics of primary testicular deficiency and interpret the results of researches.

66 Name principal reasons of origin and laboratory diagnostics of gynecomastia.

67 Explain Clinical-diagnostic value and essence of provocative test with progestagen for diagnostics of amenorhea. Interpret results of researches.

68 Point the algorithm of researches of patient with suspicion on amenorhea. Name basic tests which are used for this purpose.

Analysis of case historyI - P. 130-138.- N of 7.1-7.4; P. 146-158.- N of 8.1-8.5; P. 178-184.- N

10.1-10.3

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Situation tasks1 Patient Н. 45 years. During 3 years suffers from difficulty in

breathing, scramble-like head pains with vomit and acute pallor of cutaneous covering which are accompanied by palpitation, shortness of breath, high blood pressure. After an attack blood pressure was normalized. Loss of body wt is 8 kg Results of analyses: AST - 15МО/l; ALT – 20 units/L; cholesterol - 6,2 mmol/L; AH - 1,81 mmol/L; glucose - 7,5 mmol/L.

What researches are needed for diagnosing; what diagnosis can be assumed: a) total protein and protein fractions; b) vanillmandelic and homovanillic acids; c) catecholamines; г) glucocorticoids?

2 Patient P. 40 years. Complications on weakness, cramps of higher and lower extremities, high bloody pressure. Results of analyses: concentration of glucose - 4,5 mmol/L; cholesterol - 6 mmol/L; calcium -2 mmol/L; phosphorus - 1,2 mmol/L; potassium - 2,9 mmol/L; sodium -180 mmol/L.

What researches are needed for diagnosing, what diagnosis can be assumed: a) alkaline phosphatase; b) thyroxine, triiodthyronin; c) aldoste-ron; d) 17-ketosteroids; e) bilirubin?

3 Fill in the table: “Pathology of hormones metabolism”, which contains such columns.

Name of pathology

Reason of develop-ment

Clinical symp-toms

Change of laboratory indexes

Diagnos-tical tests

Results of tests Additional researches

Norm Patho-logy

Bring in such pathological conditions into the table: hypopituitarism, acromegaly, giantism, diabetes insipid, Cushing’s disease, Cushing’s syndrome, Addison’s disease, pheochromocytoma.

LiteratureI - p. 109-146, 161-174.

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LESSON 9Theme. Clinical-laboratory diagnostics of functional activity of thyroid and parathyroid glands. Biochemical investigation of disorders of calcium, phosphates and magnesium metabolism

Questions for preparation1 General description of hormones of thyroid gland: metabolism,

biochemical and physiology effects, regulation of secretion.2 Diseases of thyroid gland, its laboratory diagnostics, screening

method.3 General characteristics of hormones of parathyroid glands.4 Disorders of function of parathyroid glands, its laboratory

diagnostics.5 Metabolism of calcium, phosphates, magnesium, its regulation.6 Disorder of calcium, phosphates and magnesium metabolism.7 Disorders of metabolism in bone tissue: rachitis, osteomalacia,,

Pedzhet’s disease.

To execute and interpret the results of experiments:1 Determination of calcium in the blood serum Principle of method: the ions of calcium in an alkaline

environment enter into a reaction with о-crezolphtalein complexon, forming complex of violet color, colouring of which is proportional to concentrations of calcium in the blood serum.

Motion of work: test tubes fill in accordance to the table.Reagent Control test,

mlStandard test, ml

Experimental test, ml

Chromogen 1,00 1,00 1,00

Blood serumStandard solution of calciumBuffer solutionН2О

--

1,000,02

-0,021,00

-

0,02-

1,00-

They maintain 10 min. at a room temperature. Measure the optical density of experimental and standard tests against a control test at length of wave of 500-600 nm (green colour filter).

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A calculation is conducted after a formula Ed · Sst

Х = , Est Х is a concentration of calcium in the blood serum;

Ed – extinction of experimental test;Est – extinction of standard test;Sst is a concentration of Sa in standard solution of 2,5g/L

Clinical-diagnostical value. Normal concentrations in the blood serum – 2,15–2,5 mmol/L.

Concentration of calcium in the blood serum rises at destruction of bones, hypervitaminosis D. Decreasing of concentration of calcium is observed at malabsorption at intestines, hypovitaminosis D, disorder of function of kidneys and at hypo function of parathyroid gland.

Reviewer scopesSerum or plasma, norm mg/100ml (mg

%) mmole/l

- blood is from an umbilical cord:

8,2 – 11,2 2,05 – 2,80

- premature children: 6,2 – 11,0 1,55 – 2,75- 0-10 days: 7,6 – 10,4 1,90 – 2,60- 10 days – 24 months: 9,0 – 11,0 2,25 – 2,75- 24 months – 12 years: 8,8 – 10,8 2,20 – 2,70- 12-18 years: 8,4 – 10,2 2,10 – 2,55- 18-60 years: 8,6 – 10,0 2,15 – 2,50- 60-90 years: 8,8 – 10,2 2,20 – 2,55- more than 90 years: 8,2 – 9,6 2,05 – 2,40

Pharmacological interference. Anabolic hormones, androgens, vitamin D, salts of calcium, estrostilben, prolonged application of diuretics (chlortalidon, ethacrinic acid, furosemide, mercury and thiazide diuretics), oestrogens, oral contraceptives, parathormone are set too high the results of researches .Underconvulsants, sparaginase, calcitonine, carbenoxolone, corticosteroids, oestrogens at menopause, phtorides, gastrine, glucagon, glucose, insulin, purges (at the surplus

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use), salts of magnesium, methycylline, mitramycine, phosphates, and oxalates, albumen, sulfates understate the results of researches,.

2 Determination of magnesium in the blood serum Principle of method: magnesium forms with the indicator calmgite

a complex which is determined photometric at length of wave of 520 nm in alkaline solution.

Motion of work: test tubes are filled in accordance to the table.Experimental

testStandard

testControl test

Working solution, mlBlood serum, mlStandard of Мg, mlН2О

30,05

--

3-

0,05-

3--

0,05Note. Maintain 5 min at 250С, measure an optimum closeness on PEC at length of wave of 520 nm against control in a cuvette with the thickness of layer 1 sm

Table of contents of magnesium, mmol/L, calculate on a formula Eexp • 0,823 mmol/L Magnesium = , Е st

where Eexp and Est is absorption according to experimental test and standard test with the concentration of magnesium of 0,823 mmole/l (20 mg/l).Clinical-diagnostic value. Normal concentration of Мg in blood

serum is 0,78-0,98 mmol/L. At toxicity of pregnant, cancer, chronic cardiac deficiency, acute and chronic pancreatitis there is the expressed decline of concentration of magnesium in the blood serum. Increase of concentration of magnesium is observed at anuria, chronic renal defficiency and at a defect of kidneys which is accompanied by hyperkaliaemia.

Pharmacological interference. Acetylsalicylic acid (protracted application), lithium, salts of magnesium, are set too high the indexes of researches, triamteren, vitamin D (at CRD). Reduction educe – amino glycosides, aldosterone, ammonium chloride, amphotericin B, salts of calcium, citrates, ethacrinic acid, furosemide, mercury and thiazide diuretics, insulin, oral contraceptives.

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3 Determination of phosphates in the blood serum and urine Clinical–diagnostical value. Normal concentrations in the blood

serum: Р (inorganic) = 0,646-1,292 mmol/L. Inorganic phosphate is increased at renal deficiency hypoparathyroidism, overdosing of vitamin D; diminishing is observed at disorder of absorption, rachitis, renal diseases.

Pharmacological interference. Androgens, vitamin D ergo- and calciferol, furosemide, СТ, hydrochlorthiazide, methicillin (nephro-toxicity), oral contraceptives, parathormone, phosphates, natrium ethidronate, tetracyclines (nephrotoxicity).

Chemical interference is caused by bilirubin, haemoglobin, detergents (dirty dishes) increase concentration of phosphates in blood. Aminoacids, acetazolamide, anaesthetic drugs, underconvul-sants, calcitonin, adrenalin, oestrogens, fructose, glucose, hydro-chlorthiazide (at the protracted application), insulin, phenothiazines reduce concentration of phosphorus.

Citrates, mannitol, oxalates, tartrates understate research results as a result of the chemical influencing.

Influence of factors on excretion of inorganic phosphorus with urine. Alanine, asparaginase, acetylsalycilic acid, acetazolamide, hydrocarbonates, salts of bismuth, calcitonin, corticosteroids, parathi-rin, mercury diuretics, phosphates, tryptophan are set too high the re-sults of researches. Mannitol understates the results of researches of.

4 Determinations of concentration of hormones of thyroid and parathyroid glands in blood serum (see class 8)

To the test control questions

1 Explain the biological role of calcium and phosphates in an organism.

2 Name mechanisms which provide saving of calcium-phosphate homeostasis in an organism.

3 For what disease such triad is characteristic: decline of concentration of inorganic phosphate, increase of activity of alkaline phosphtase, increase of coefficient of Са/Р: a) osteopo-rosis; b) osteoma; i) rachitis; г) hyperparathyrosis?

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4 The level of what elements in the blood serum depend on the function of parathyroid glands: a) potassium; b) sodium; c) calci-um; d) phosphate; e) iodine; f) copper?

5 Level of what elements in the blood serum depends on the function of thyroid: a) potassium; b) sodium; c) calcium; d) phosphate; e) iodine; f) copper?

6 What principles of endocrine glands have regulation activity?7 What hormones are produced by a thyroid gland? Their biological

action.8 Give clinical-laboratory description of disorder of functions of

thyroid gland.9 What biological role of hormones of parathyroid glands?10 Describe the clinical-laboratory picture of disorders of function of

parathyroid glands.11 What methods are used in our time for determination of

concentration of hormones in the blood serum and urine?12 In what consists laboratory diagnostics of hyperparathyreosis:

а) determination of level of calcium in blood and urine; b) deter-mination of level of phosphate in blood and urine; c) determina-tion of activity of alkaline phophatase?

13 Schematically represent metabolism of thyroid hormones with pointing of regulator mechanisms of its secretion.

14 Name laboratory tests of function of thyroid gland which are used for diagnostics. In detail describe one of the most informing tests.

15 Explain, in which cases expedient determination of concentration of free thyroxine (Т4) and triiodothyronine (Т3) in blood. Ground an answer.

16 Explain in which cases we need determination of concentration of thyrotrophic hormone (TTH) in blood. Explain the answer.

17 Explain in which cases we need conducting of test with a thyrotrophin-releasing-hormone (ТRH).

18 Explain, how concentration of ТТH and Т4 will be changed in plasma at:

а) primary hypothyroidism; b) euthyroidism; c) hyperthyroidism.

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19 Explain how concentration of ТТH and Т4 will be changed in plasma at:а) hypofunction of hypophysis; b) subclinical hyperthyroidism; c) euthyroidism with autoantibodies to Т4.

20 Explain how concentration of ТТH and Т4 will be changed in plasma at: а) convalescence after euthyroidism; b) Т3-thyrotoxi-cosis; c) compensated hypothyroidism.

21 Name possible reasons of development and basic metabolic changes at hypothyroidism.

22 Name obligatory and additional laboratory researches which are appointed for diagnostics of diseases of thyroid gland.

23 What methods do they use for the exposure of thyroid status of organism and screening method of diseases of thyroid gland?

24 Depict electrophorogram of proteins of blood serum at hypothyroidism. Explain reasons of change of spectrum of proteins at this pathology.

25 The changes of what biochemical indexes of blood do characterise disorder of proteins exchange at hyperthyroidism? Explain an answer.

26 Name the changes of biochemical indexes of blood at hyperthyroidism. Explain the answer.

27 Schematically represent metabolism of calcium in an organism.28 Name the basic forms of calcium in plasma. Name percentage

correlation of these forms. Which factors can influence on maintenance of calcium in plasma?

29 Name the basic biochemical and physiology effects of parathyroid hormone.

30 Schematically represent metabolism of calcitriol with describing of its basic functions and regulation of synthesis.

31 Schematically represent a homeostatic answer on hypocalcaemia. Explain the picture.

32 Schematically represent a homeostatic answer on hypophosphatemia. Explain the picture.

33 Explain the reasons of development of hypercalcaemia at malignant diseases.

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34 Explain the reasons of development of second and tertiary hypercalcaemia.

35 Explain development of hypercalcaemia at thyrotoxicosis.36 Name the reasons of development of hypercalcaemia.37 Name biochemical tests which is expedient to appoint for

determining of reasons of hypercalcaemia.38 Name the reasons of development of hypocalciaemia.39 Explain the reasons of development of hypocalciaemia at the

deficit of vitamin D.40 Explain the reasons of development of hypocalciaemia at

diseases of kidneys, pancreatitis and deficit of magnesium.41 Explain the reasons of development of hypocalcaemia at

hypoparathyroidism.42 Name the reasons of development of hyperphosphataemia.43 Name the reasons of development of hypophosphataemia.44 Name the basic changes of biochemical indexes of blood at:

а) osteoporosis; b) renal failure.45 Name the basic changes of biochemical indexes of blood at:

а) osteomalacia; b) primary hyperparathyreosis.46 Name the basic changes of biochemical indexes of blood at:

а) Pedzhet’s disease; b) osteoporosis.47 Name the principal reasons of development of rachitis and

osteomalacia.48 Name the principal reasons of development of osteoporosis.49 Describe the metabolism and biological role of magnesium in an

organism.50 Explain the reasons of development of hypomagnesemia.

Analysis of case historyI - P. 168-173, 9.1; 9.2; 9.3; 9.4; 9.5. I - P. 219-230, 12.1; 12.2; 12.3; 12.4; 12.5; 12.6.

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Situation tasks1 Sick С. 60 years. Complains on pain in bones, muscular weakness,

diarrhea, nausea, vomitting, and pains in a stomach. In research, founded stone in kidneys. Results of analyses: concentration of glucose - 4,5 mmol/L; bilirubin - 15 μmol/L; urea - 5 mmol/L; calcium - 3,6 mmol/l; sodium - 140 mmol/L. What researches are needed for determining of diagnosis what diagnosis can be assumed: a) amino-transferases; b) concentration of phosphate in blood and urine; c) cate-cholamines; г) parathyrine?

2 Sick M. 25 years. She was often ill quinsies. During a year there is palpitation, strong fatigueability, and shortness of breath, tremor of fingers of hands. Loss of wt 6 kg. Complain about feeling of «internal anxiety», bad sleep, sweatiny. Results of analyses: concentration of glucose - 6,5 mmol/L; cholesterol - 3,11 mmol/L; total protein - 62 g/L; albumens - 51,5 %, α1-globulines - 5,1 %; α2 - 8%; β - 10%; γ- 25%. What is necessary to carry out for clarification of diagnosis what diagnosis is it possible to assume: a) parathyrine; b) aldosteron; c) proteininherited iodine; г) thyroxine, triodthyronine?

LiteratureI – p. 147-160, 199-214.

LESSON 10Theme. A clinical estimation of biochemical indexes is at liver

and biliary ways diseases

Questions for preparation1 Basic functions of liver.2 Metabolism of bilirubin.3 Biochemical methods of estimation of liver functions: tests which

characterise the metabolic functions of liver; enzymes as functional tests of liver; tests which characterise detoxication and excretory functions of liver.

4 Syndrome classification of liver function tests.5 Functional biochemical description of basic nosological forms of

diseases of the hepatobiliary system.

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6 Algorithm inspections patients with pathology of the hepatobiliary system and laboratory tests which are used on the different stages of diagnostics.

7 Laboratory diagnostics of the inherited desorders of metabolism of bilirubin and other diseases of liver.

8 Hepatotoxical substances.

To execute and interpret the results of experiments1 Quantitative determination of general, direct and indirect

bilirubin in the blood serum (after the method of Iendrashek) Principle of method: diazosolution gives the rose colouring with

direct (connected) bilirubin. Intensity of colouring solution (azobilirubin) is proportional to the concentration of direct bilirubin and can be certainly photometric. Indirect (free) bilirubin can be transformed into the soluble condition by adding to the blood serum of caffeine reagent which promotes solubility of this pigment, and is defined with diazo reaction. General concentration of both forms of bilirubin makes total bilirubin. After a difference between the amount of total and direct bilirubin the level of indirect bilirubin is determined.

Motion of work: the blood serum is diluted with a 1:1 0,9% solution of NaCl. Test tubes are filled in accordance with a table.

Number of test tubes 1(ml)

2(ml)

3(ml)

Reagent Direct bilirubin

Control Total bilirubin

Serum, ml 0,5 0,5 0,5NаСl, 0,85%, ml 1,75 0,25 —Diazo solution, ml 0,25 — 0,25Caffeine reagent, ml — 1,75 1,75

Mix and abandon test tubes on 10 min. They provide photometric measurements at a green colour filter (530 nm) in a cuvette 5 sm against control. They find concentration of direct and general bilirubin. After the difference of total and direct bilirubin concentration of indirect is calculated.

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A calculation is conducted after a formula Х = Е •11,5•17,1 μmol/l or after a calibrate graph

Clinical-diagnostic value. In a norm concentration of total bilirubin is 8,5-20,5 μmol/l (0,1-1,2 mg/100ml), indirect – 1,7 - 17,1 μmol/l (0,1-1,0 mg/100 ml) and direct – 0,86-5,1 μmol/l (0,05-0,25 mg/100 ml). Blood of new-born differs with higher concen-tration of bilirubin (23,1 μmol/л).

Increasing bilirubin in the blood of higher than 27,36 - 34,20 μmol/l causes depositing of it in tissues, appearances of jaundices icterus. At a hemolytic jaundice a liver does not have enough time to connect plenty of indirect (free) bilirubin which appears as a result of increased hemolysis of red blood cells. As a result in plasma of blood look after the increased concentration of indirect bilirubin is observed.

A parenchymatous jaundice arises up at hepatitis (viral, toxic), cirrhosis of liver. As a result of damage of membranes of hepatocytes direct bilirubin partly gets back in blood. In addition ability of liver to detoxicate indirect bilirubin goes down. As a result of parenchymatous jaundice at different degree of bilirubinemia due to faction direct and indirect bilirubin can be observed.

Under cholestasis as a result of obstructive stopping up (by stones, by a tumour) of bilious channels a bile overfills them and goes in the river-bed of blood. That is why bilirubinemia (to 170 - 700 μmol/l) will be expressed mainly due to fraction of direct bilirubin.

2 Determination of cholinesterase activity in blood Principle of method: under action of cholinesterase take place at

hydrolysis of acetylcholine with formation of vinegar acid and choline. Vinegar acid reduces рН solution which is set by an indicator (a change of colouring is due to raspberry rather yellow color).

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Motion of work: before work all of the tools must be warmed up to temperature of +370С.

Reagent, ml Experimental test, ml

Control test, ml

Standard test, ml

Buffer indicator mixture 2,5 ― 2,5Serum 0,05 0,05 ―Н2О ― 2,7 0,05

Acetylcholinechloride 0,1 ― 0,1They incubate mixture during 30 min at the temperature of 370С

Proserin 0,1 ― 0,1Note. Measure the optical density of tests against the distilled water at 540 nm (green colour filter; cuvette 1 sm)

The results are transfered after a formulaEst + Ec – Eexp

where Est, Ec and Eexp is absorption in standard, control and experimental tests.

A calculation is conducted after a calibrate graph. If an optical density of experimental test against the distilled water is lower than 0,1 ones, the experimental serum is soluted in two times with water and multiple determination is provided (an eventual result is multiplied on 2).

Clinical-diagnostic value. In a norm activity of enzyme in the blood serum is 45-95 μmol/(s·l), or 160-340 μmol/(h·ml).

Cholinesterase (CE) synthesis is violated and its activity decreases in serum under the liver parenchymadisease. Under acute hepatitis approximately in 85% of cases hypocholinesteremia is observed, decreasing of activity begins in a few days after the manifestation of disease, later is observed manifestation of other important clinical-biochemical tests. Determination of CE activity has a prognostic value in this case. Activity is normalized before normalization of most of the tests which are used for functional research of liver. Hypocholinesterasemia is observed at cirrhosis; at the obstructive jaundice activity is normal.

Chemical and pharmacological interference. Reduction activity: urethane, cyclophsphamide, oestrogens, neuromuscular relaxants (pancuronium, succinylcholine), oral contraceptives, organophospho-

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rous insecticides, phenothiazines, X-ray contrast substances, testosterone, borates, citrate, fluoride, pyrophosphate, tertiary and quaternary amines.

3 Determination of activity of γ-GTP in the blood serum Principle of method: γ-glutamintranspeptidase catalyses reaction

transference of residual L-γ-glutamine from chromogen substratum on glycilglycine. At this reaction p-nitro-aniline releases, the optical closeness of which is determined with photometrical muasurement.

Motion of work: determination is conducted pursuant to the sequence of operations, marked in a table.

Reagent Experimental test, ml Control test, mlSustratal-buffer solution

0,5 0,5

In a thermostat on 5 min at 370СBlood serum 0,05 -

Mix, incubate 15 min at 370С10% vinegar acid 3,0 3,0Blood serum - 0,05Note. Measure extinction of experimental test against control at λ=400-420 nm in a cuvette with the thickness of layer 5 sm. Determine activity of enzyme after a calibrate graph

Clinical-diagnostic value. Normal values: - for the men 250-1767 nmol/s·l (0,9-6,4 μmol/h·ml);- for the women of 167-1100 nmol/s·l (0,6-0,4 μmol/h·ml).

γ-GTP is contained in a liver, kidneys, and pancreas. The considerable increases of activity of enzyme is observed at the diseases of liver and biliary ways with the phenomena of obturation of different genesis, hepatitis. Moderate increase at: tumours of liver, chronic alcoholism, damage of parenchyma of kidneys, poisoning by hepatotropical poisons. The increase of activity of γ-GTP at the heart attack of myocardium after the second week testifies favorable motion of disease.

Pharmacological interference: increasing is induced by barbiturates, ethanol, acetaminophen, phenition, streptokinase, hepatotoxic preparations.

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4 Determination of activity of alkaline phophatase in serum see lesson 14

5 Qualitative reactions on bilious pigments in urine Clinical-diagnostical value. Bilious pigments (bilirubin,

biliverdin and other) appear in urine as alkaline salts at hepatitis. Bilious pigments appear from hemoglobin into whan breaking up of red blob cells.

Control questions1 What enzymes are most important in diagnostics of liver diseases?2 Where is unconjugated bilirubin is formed? How does it transform

hepatocytes?3 How does conjugated bilirubin transforms in biliary ways?4 Name basic factors which cause disorder of exchanges of bilious

pigments.5 What can we find out with such laboratory indexes: reaction of

urine on bilious pigments, urobilinoids?6 Point differential diagnostics of hemolytic and obstructive jaundice

with the informations of laboratory analyses.7 Point differential diagnostics of obstructive and parenchymatous

jaundice (on peak of disease) according to laboratory tests.8 Can we determine acholic form of hepatitis on the indexes of

metabolism of bilious pigments?9 What particle is made by conjugated bilirubin of blood in a norm:

а) 5 %; b) 25 %; c) 50 %; d) 75 %?10 Urine of healthy man is contained: a) urobilinogen; b) sterco-

bilinogen; c) mesobilirubin; d) urobilin?11 In what form of jaundice positive reaction of urine on bilious

pigments appears: a) parenchymatous; b) obstructive; c) hemo-lytic; d) neonates?

12 In what forms of jaundice positive reaction of activity of alkaline phophatase took part: a) parenchymatous; b) obstructive; c) he-molythic; d) neonates?

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13 In what forms of icterus fraction of conjugated bilirubin prevails in blood: a) parenchymatous; b) hemolytic; c) obstructive; d) neo-nates?

14 What researches is it necessary to appoint for early diagnostics of acute viral hepatitis?а) fractions of bilirubin; b) ALT; c) AST; г) stercobilin of urine?

15 With what laboratory analyses is it possible differentiate hemolytic jaundice from obstructive on peak of disease: a) frac-tions of bilirubin; b) amount of reticulocytes; c) concentration of iron in serum; d) activity of alkaline phophatase?

16 What laboratory tests are provided at differential diagnostics of parenchymatous and hemolytic jaundice: a) fractions of bilirubin; b) thymol test; c) iron in serum; d) isoenzymes of LDH?

17 What researches will be provided at the acholic form of infectious hepatitis: a) activity of alkaline phosphatase; b) fractions of bilirubin; c) activity of aminotransferases; g) thymol test?

18 Describe the role of liver in the metabolism of carbohydrates and lipides.

19 Describe the role of liver in an protein metabolism.20 Describe the role of liver in the metabolism of vitamins,

hormones, microelements.21 Name the basic sources of bilirubin in an organism.

Schematically represent its metabolism.22 Explain what fraction of bilirubin is present in urine at

bilirubinuria. 23 Explain, during what concentration of bilirubin in blood clinical

signs of jaundice appear: a) 8,5 μmol/l, b) 20,5 μmol/l, c) 30 μmol/l, d) 50 μmol/l?

24 Give examples of blood serum proteins, determination of which has a diagnostic value under the liver diseases. How does their concentration change at pathology?

25 What functional tests can be used for the explanation the role of liver in protein metabolism.

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26 Why the determination of protein spectrum of blood is importance for diagnostics of liver diseases?

27 Name clinical-diagnostic value of determination of sedimentary tests for diagnostics of liver diseases.

28 Why the determination of urea and ammonia in the blood serum is importance of liver diseases?

29 Esplaine clinical-diagnostic value of determination of amino acids spectrum and phenol in blood for diagnostics of liver diseases.

30 Determination of concentration of urea in the blood serum is used for the estimation of degree of weight of structural damages of liver. Whether the use of this test is possible for the early diagnostics of pathology of liver? Explain your answer.

31 Esplaine clinical-diagnostic value of determination of bilirubin and its fractions in blood for differential diagnostics of different gene-sis jaundice. Give examples.

32 Esplaine clinical-diagnostic value of determination of bilirubin and urobilinogen in urine, stercobiline in faeces for differential diagnostics of jaundice of different genesis. Give examples.

33 Name principal reasons of origin and classification of jaundice.34 What obligatory and laboratory researches of blood, urine and

faeces must be conducted at suspicion on pathology of liver?35 What screening laboratory researches must be conducted for

diagnostics of functional activity of liver?36 Esplaine clinical-diagnostic value of determination of free bilirubin,

conjugated bilirubin and bilious acids in blood.37 What laboratory tests are most informing in diagnostics of

damages of liver parenchyma?38 Esplaine clinical-diagnostic value of determination of glutamate

dehydrogenase (GDH) for diagnostics of jaundice. Explain a notion “Shmidt’s coefficient”.

39 Select laboratory tests for diagnostics of cholestasis.40 What laboratory researches are used for research of the excretory

function of liver? Explain their purpose.41 What laboratory researches are used for an estimation of

detoxical functions of liver? Explain their purpose.

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42 Name laboratory tests which are used in hepatology as indicators of cytolysis.

43 Name laboratory tests which used in hepatology as indicators of hepatodepressive syndrome.

44 Name laboratory tests which are used in hepatology as indicators of mesenchymal-inflammatory syndrome.

45 What laboratory tests are used in hepatology as indicators of shunting of liver?

46 What laboratory tests are used in hepatology as indicators of regeneration and tumour growth?

47 What changes in the biochemical analysis of blood will be in case a hemolytic jaundice. Select the most important laboratory indexes for diagnostics of hemolytic jaundice.

48 What changes in the biochemical analysis of blood will be in case acute hepatitis? What tests are most important for diagnostics of this pathology?

49 What changes in the biochemical analysis of blood take a place at chronic hepatitis? What tests are most important for diagnostics of this pathology?

50 What changes in the biochemical analysis of blood will be in case the cirrhosis of liver? What tests are most important for diagnostics of this pathology?

51 What changes in the biochemical analysis of blood will be in case a hepatic jaundice? What tests most informing for diagnostics of this pathology?

52 What changes in the biochemical analysis of blood will be in case obstructive jaundice? What tests are most important for diagnostics of this pathology?

53 Compare the changes of biochemical indexes of blood and urine at a hemolytic and hepatic jaundice.

54 Compare the changes of biochemical indexes of blood and urine in case a hemolytic and mechanical jaundice.

55 Compare the changes of biochemical indexes of blood and urine in case a hepatic and mechanical jaundice.

56 Choose laboratory tests for diagnostics of hepatic comma.

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57 What obligatory laboratory researches must be appointed for diagnostics of diseases of gall-bladder and bilious channels?

58 Select laboratory tests for determining of nosology diagnosis at the inspection of patients with pathology of the hepatobiliary system?

59 Select laboratory tests for clarification of activity of pathological process, stage of disease, presence of complications at the inspection of patients with pathology of the hepatobiliary system?

60 Name the reasons of development of Gilbert’s syndrome. What changes of biochemical indexes of blood and urine take a place at this pathology?

61 Name the reasons of development of Crigler-Najjar syndrome. What changes of biochemical indexes of blood and urine take a place at this pathology?

62 Name the reasons of development of Dubin-Johnson syndrome. What changes of biochemical indexes of blood and urine take a place at this pathology?

63 What changes of biochemical indexes of blood take a place for patients with Wilson’s disease?

Analysis of case historyI - P. 98-100 - N 5.1-5.4; P.103-105 - N 5.5-5.7.

Situation tasks1 Patient M. was hospitalized with the expressed jaundice, by

complaints about sense of weight in a epigastric area and right hypochondria, itch, fatigue ability, crabbiness. At a laboratory inspection it was determined: hyperbilirubinemia with the overwhelming increase of conjugated bilirubin, thymol test in a norm, ALT is moderately increased.

What diagnosis can be assumed: 1) acute hepatitis; 2) mechanical jaundice; 3) hemolythic jaundice; 4) Crigler-Najjar syndrom? What enzymes tests must be executed for clarification of diagnosis: 1) Cholinesterase ; 2) alkaline phosphatase; 3) SDH; 4) aldolase; 5) LDH?

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2 Sick I. was hospitalized in a grave condition with the phenomena of jaundice, weakness, blurr consciousness. At a laboratory inspection was discovered: bilirubinemia is expressed with the overwhelming increase of conjugated bilirubin, activity of ALT within the limits of norm, Cholinesterase is considerably reduced.

What diagnosis can be assumed: 1) cirrhosis of liver; 2) acute yellow atrophy of liver; 3) mechanical jaundice? What researches are needed for clarification of diagnosis: 1) AST; 2) Sorbitoldehydrogenase; 3) thymol test; 4) isoenzymes of LDH?

3 Sick B. was operated in a clinic concerning cholelithiasis. As anesthetic myorelaxants were used. During an operation the stop of cardiac activity happened at sick. What diagnosis it is possible to assume: 1) overdosing of narcotic facilities; 2) born deficit of Cholinesterase activity; 3) cardiac deficiency; 4) allergic reaction? What enzymic tests must be provided for determining of reason of sudden complication: 1) Cholinesterase; 2) alkaline phosphatase; 3) ALT; 4) creatine kinase; 5) isoenzymes of LDH?

4 Patient Z. 48 years. Complaint about the promoted fatigue ability, bad appetite, soon the protracted nausea appeared and once or twice there was vomiting a meal. To the end of the first week a weakness increased sharply. It is marked at a clinical review: a liver is near the edge of costal arc. Analyses from the beginning of disease:

Laboratory index Norm Through3 weeks

Through4 weeks

Bilirubin, μmol/l To 20,52 20,52 8,55Conjugated bilirubin μmol/l To 5,13 10,26 5,13Thymol test, odes. Sulemic test, ml of sulemic reagent Urobilinoids Bile pigments

0—41,6—2,2

Norm -

4,201,60

Norm -

4,402,0

Norm -

1) What pathology can be assumed? 2) What additional laboratory researches would help in determining of diagnosis?

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5 Patient A. 56 years complained about a general weakness, nausea, inexpressive pains in the stomach of aching character, belch with «rotten eggs». An appetite is bad. In three days urine become dark and an jaundice appeared. Was hospitalized on a 4th day from the beginning of disease. At an inspection the increase of liver the edge of which came forward on 3 - 4 sm. from under a costal arch was marked.Results of laboratory researches:

Laboratory index Norm Icteric periodon a 3th day on a 10th

dayon a 17th

day

1 2 3 4 5Total bilirubin, μmole/lCholesterol, mmole/lALT, mmol/(h·l)AST, mmol/(h·l)AP, mmol/(h·l)

To 20,523—6,2428—19028—125278-830

107,737,8 8164—

194,949,1522231051653,2

259,9213,6762961481701,4

Index of Protrombin, %Haemoglobin, g/lSedimentation test, mm/hUrobilinoidsBilious pigmentsStercobilin of faeces

70—110120-1401—10Norm—+

9512330 +++++ + -

—13830+++++-

6214230—++++—

1) About what disorder of metabolism of bilious pigments is it possible to discuss? 2) What additional laboratory researches is it expedient to conduct?

6 Gather additionally the most important connection of enzymes for the inspection of patients with the diseases of liver: 1 Amylase. 2 Uropepsino-gen. 3 Lipase. 4 Acid phosphatase. 5 ALT. 6 AST. 7 Sorbitol dehydroge-nase. 8 Alkaline phosphatase. 9 Glucose-6-phosphate dehydrogenase. 10 Cholinesterase. 11 Lactatt dehydrogenase. 12 Isoenzymes of lactate dehydrogenase 13 Trypsin. 14 Catalase. 15 Creatinekinase. 16 Fructose-1,6-diphosphataldolase. 17 Fructosmonophosphatealdolase. 18 Ceruloplas-mine. 19 Carboanhydrase. 20 Monoaminooxidase. 21 Acetylcholineste-rase. 22 Hexokinase. 23 Arginase. 24 Adenosindesaminase. 25 Trans-amidinase. 26 Urokinase. 27 Leucinaminopeptidase. 28 Isoenzymes of ma-latdehydrogenase. 29 Isoenzymes of alkaline phosphatase. 30 Isoenzymes of amylase.

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7 Gather additionally of the most rational connections of enzymic tests at the liver diseases for the decision of such clinical tasks: a) early diagnosis; b) differential diagnosis; c) estimations of degree of damage of parenchyma; d) estimations of degree of cholestasis; e) prognosis; f) estimations of transition of acute hepatitis into chronic: 1 ALT. 2 AST. 3 Malatdehydrogenase. 4 Lactate dehydrogenase. 5 Aldolase. 6 Phospho-fructaldolase. 7 Alkaline phosphatase. 8 Sorbitol dehydrogenase. 9 Iso-citrate dehydrogenase. 10 Glutamate dehydrogenase. 11 Ornitincarba-moiltransferase. 12 Cholinetherase. 13 Adenosindeaminase. 14 Isoenzymes of lactate dehydrogenase. 15 Isoenzymes of malate dehydrogenase. 16 Iso-enzymes of alkaline phophatase. 17 γ-GTM. 18 5-nucleotidase.

LiteratureI – p. 77-94.

Lesson 11Theme. A clinical estimation of biochemical indexes

in kidneys diseases

Questions for preparation1. Features of metabolism in kidneys in a norm and at pathology.2. Biochemical kidneys functions tests.3. Organ-specific enzymes in diagnostic of kidneys diseases.4. Research of proteins spectrum of blood and urine at pathology of

kidneys. Proteinurias.5. Clinical laboratory diagnostics of basic nosology forms of kidneys

diseases.

Perform and interpret the results of experiments 1 Hemorenal tests Normal values of clearence of kreatinine (for N.U. Titsem):

ml/(min • 1,73 м3) ml/(s • м2)- men 97-137 0,93-1,32;- women 88-128 0,85-1,23.

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Change: ml/(min · 1,73 м3) ml/(s · м2)- insignificant 52-62,5 0,50-0,60;- easy 42-52 0,40-0,50;- moderate 28-42 0,27-0,40;- fully expressed <28 <0,27.

Coefficient of transition ml/(min·1,73 м2) in ml/(s·м2) – 0,00963, opposite – 104.

Clinical-diagnostic value. The increase of glomerular filtration rate is observed at the promoted cardiac spike, pregnancy, burns, poisonings by the oxide carbon (ІІ); protein diet, hypercatabolism. Diminishing of glomerular filtration rate (decline of glomerular clearence) is observed at the decline of kidney blood stream: shock, bleeding, hypohydratation, cardiac insufficiency, high blood pressure, diabetes mellitus; born pathology of kidneys, glomerulonephritis, nephrotic syndrome, pyelonephritis, acute renal tubular disorder, urinary obstruction. Diminishing of glomerular filtration rate develops at extrarenal pathologies: malaria, myeloma, hypocorticism, cystinosis, hepatocerebral degeneration, vitamin-resistance rachitis, chronic obstructive diseases of lungs, renal deficiency, eclampsy and preecalmpsy.

Pharmacological interference. Promote clearence of creatinine: furosemide, methyprednisolone, carbenoxolon; levodopa (at using of method of Yaffe). Reduce of creatinine clearance: diazoxide, thiazide diuretics, triamteren, nephrotoxical preparations; a temporal effect is given by cannabis and heroin.

2 Determinations of activity of transamidinase in the blood serum Clinical-diagnostic value. A considerable increase is caused by

chronic pyelonephritis in the phase of violation of nitrogenexctertory function, chronic nephritis in a terminal phase, nephrotic syndrome, predefined by the amyloidosis of kidneys and thrombosis of kidney veins.

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Moderate increase: chronic nephritis with the isolated urinary syndrome without violation of nitrogenexctertory function, remaining phenomena of sharp nephritis.

Chemical and pharmacological interference. Promote: activity vitamin D, gold, salycilates, amphotericin B, ampicillin, gentamycin, isonicotinic acid hydrazide, kanamycin, furadonine, streptomycin, sulfanilamides, X-ray contrast substances and other nephrotoxical preparations. 3 Determination of urea in the blood serum

Principle of method: an urea forms from diacetylmonooxime at presence of ions of Fе3+ and thiosemicarbazide complex of red color after intensity of colouring of which its concentration is determined.

Motion of work: they fill 3 test tubes (in accordance with a table. For diminishing of analysis error it is recommended that to adhere the stated below order of mixing of solutions.Notes:1 If concentration of urea is a more than 25 mmol/l test solution

must be diluted by distilled water and analysis is repeated. To increase a result on breeding.

2 Hemolythic and lipaemic serum are deproteinated. For this purpose 0,1 ml of serum is mixed up with 0,9 ml of solution of trichloroacetic acid and is centrifugated during 5 min. The same way process a standard. For an analysis take away 0,1 ml centrifugate and conduct research the same as for a serum without deproteinating. It is possible to research urine with this method

Reagent Test tubesexperim

ental standard control

Blood serumStandard solution of ureaН2ОSolution of diacetylmonooximeSolution of thiosemicarbazide

0,02 ml--

2,00 ml2,00 ml

-0,02 ml

-2,00 ml2,00 ml

--

0,02 ml2,00 ml2,00 ml

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Test tubes are closed with aluminium foil, concentration of test tubes is mixed and boiled on the aquatic bath-house of exactly 10 min. At the same time experimental, standard and control tests are processed.

Then test tubes quickly cool under the stream of cold water. Experimental and standard tests are calculated against control at wave length of 530-560 nm (green colour filter) in a cubic with the thickness of layer 1 cm. It follows to conduct measuring of optical closeness during no more than 15 min after cooling.

If after heating solution in the first test tube is turbid, they centri-fugate it during 5 min, or deproteinate solution of trichloroacetic acid.

Calculation. The concentration of urea is determined by formula Eexp

C = · 16,64 mmol/l Est

where С is a concentration of urea;Eexp is an optical closeness of experimental test;Est is an optical closeness of standard test.

Clinical-diagnostic value Normal concentration of urea:

- in the blood serum (3,3-8,3) mmol/l;- in urine (333-583) mmol/day, (20-35) g/day.

The increase of index is observed at cardiac deficiency, diminishing of supplies of salts and water at vomit, diarrhea, promoted diuresis or sweating, shock states, promoted catabolism of albumens, diet with high concentration of proteins, acute and chronic diseases of kidneys.

The decline of index is observed at a diet with low concentration of proteins and high concentration of carbohydrates, pregnancy, acromegaly, parenteral feed, hard diseases of liver, violation of absorption.

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Pharmacological aspects. Promote concentration of nitrogen of urea in blood: amphotericin B, gentamycin, geramycin, dopegit, aldomet, methyldopa, indomethacine, indocide, metycillin, nalidoxone acid, nevigramon, negram, neomycin, arsenic compounds, octadine, sanotensin, ismelin, compounds of mercury, stibium, tetracyclines, triamteren, furadonin, nitrofurantoin, furosemid, ceporin.

Chemical interference is given by chloralhydrate, levomycetin, salts of the ammonium, chlorbutanol, gunetidine, acetohexamide (at the use of method of Nessler).Somatotrophic hormon, glucose, derivatives of thiazide, are reduce of nitrogen Concentration.4 Determination of creatinine in the blood serum

Principle of method: creatinine reacts with picric acid in an alkaline environment with formation of red tautomer creatinine picrate, which predetermines appearance of the proof orange-red colouring. Intensity of colouring is proportional to the concentration of creatinine.

Motion of work: test tubes are filled according the a table.Reagent Test tubes (ml)

experimental standart controlBlood serum, ml 1,0 - -Working standard solution of Creatinine, ml

- 1,0 -

Picric acid (satur.) 3,0 3,0 3,0To cure during 5 min at 25 оС, then to place in an aquatic bath-house at 100 оС on 15-20 s.

Centrifugate10 min at 3000 revo

Centrifugate, ml 2,0 - -NaОН –10%, ml 0,1 0,1 0,1

The general volume of solutions is led to 10 ml water. After 10 min (not later than in 20 min) they provide calorimetry in a cuvette with the thickness of layer 1 cm at wave length of 500-560 nm (green colour filter) against a control test.

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The calculation of concentration of creatinine (Х) is calculated by formula 0,1mmol/l ·Eexp

Х= Est

where Ed – extinction of experimental test;Est – extinction of standard test;0,1 is a concentration of creatinine in a standard test (mmol/l) (if a

standard test has other concentration of creatinine, correlations of extinction of experimental and standard tests multiply on its value).Linear dependence between the size of extinction and

concentration of creatinine is saved only during its concentration within the limits of 0,026-0,352 mmol/l. If it is possible to hope on the higher values of concentration, serum must be divorced in 2-4 and more times with solution and in the formula resulted higher to enter this size (to multiply findings on the size of solutation).

Clinical-diagnostic value. Concentration of creatinine in blood in a norm is 53-106,1 μmol/l. Determinations of concentration of creatinine in the blood serum is conducted for research of the renal function– glomerular vehicle, volume or glomerular filtration rate.

A growth of concentration of creatinine is observed at disorder of kidneys function (acute and chronic), at intestinal impassability, obturation of urinary ways, hyperfunction of adrenal glands.

Creatinine is attribute to the non-threshold substances, that it is filtrated only by glomerules and is not reabsorbed. The declines of level of creatinine in the blood serum is observed at a muscular weakness, pregnancy.

Clinical and chemical interference: clinical growth is determined by nephrotoxical preparations. Increase of creatinaemia is predefined by the chemical influencing, bromsulfophtalein, phenolsulfophtalein, acetoacetic acid, ascorbic acid, levodopa, methyldopa, glucose, fructose.

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Determination of pathological components in urine 5.1 Qualitative reactions on proteins in urine 5.1.1 Qualitative reaction on proteins with sulfosalycilic acid

Principle of method: the amount of proteins in urine of healthy man is so low, that it does not appear in ordinary reactions which are used in a clinical laboratory. For determination of protein in urine the reactions of besieging by nitric or sulfosalycilic acids are used. Last is most sensible.

Motion of work: they added 3 drops a 20% solution of sulfosalycilic acid to 1 ml urine. At presence of proteins white sediment (or dimness) appears in urine the degree of which depends on the concentration of protein in urine. For comparison the same reaction is conducted with urine of healthy man.

5.1.2 Heller’s reactionMotion of work: they bring in 10 drops of the concentrated nitric

acid in a test tube. Inclining a test tube under the corner of 450, carefully on its wall urines (10 drops) they add the same volume so that both liquids were not mixed up. At presence of albumen on verge of two layers of liquids sediment appears as a small white ring. If they add surplus of the concentrated nitric acid, sediment does not disappear.

Clinical-diagnostic value. It is found out that proteins in urine at a nephrite (that at inflammation of vascular balls of kidneys, when their permeability is increased), in the cases of cardiac decom-pensation, at some forms of the increased pressure, sometimes at pregnancy, and also at inflammation of urinary ways.5.2 Qualitative test on blood pigments in urine (benzidine test)

Principle of method: benzidine is oxidized by atomic oxygen, which appears at destruction of hydrogen peroxide by blood pig- ment – haemoglobin which gives a peroxidase action.

Motion of work: they pour in the test tube 1-2 ml of fresh unstrained urine, boil and cool. The same volume of benzidine and a few drops of Н2О2 are added. At a positive reaction there is appearance of the dark blue or green colouring of oxidizing benzidine products by blood pigment due to oxygen of Н2О2.

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Clinical-diagnostic value. Hematuria (blood in urine) is observed at the damage of urogenital ways; hemoglobinuria (blood pigments in urine) is observed at poisoning by hemolythic poisons and at number of diseases, related to hemolysis of red corpuscles. In case of hematuria and hemoglobinuria there is a protein in urine. 5.3 A Qualitative reaction on glucose in urine (Trommer’s test)

Motion of work: 1 ml of a 10% solution of NaOH is added to 1 ml of urine and then 0,5 ml of a 1% solution of sulfate of copper is added too. They heat carefully overhead part of concentration of test tube to effervescence and boil exactly 1 min. The red colouring – positive reaction appears in the presence of glucose.5.4 A Qualitative reaction on ketone bodies

5.4.1 Legal’s test on an acetone and acetoacetic acidPrinciple of method: an acetone and acetoacetate from natrium

nitropruside in an alkaline environment form the products of reaction painted in a red color. Complex salt of cherry-red color appears at adding of the concentrated vinegar acid.

Motion of work: they bring urines for 0,5 ml in two test tubes: in the first – healthy man (control), in second – patient with saccharine diabetes. In both test tubes 0,5 ml of solution of caustic sodium and 5-7 drops of natrium nitropruside are added. They look after appearance of the red colouring in the second test tube (urine of patient). They acidify solution with a few drops of the concentrated vinegar acid. The red colouring acquires a cherry tinct.

5.4.2 Gerkhard’s reaction on acetoacetic acidPrinciple of method: sediment of phosphates fall out at adding

to urine of solution of chloric iron (FePO4). At presence of acetoacetic acid after addition surplus of chloric iron of there is the cherry-red colouring. After some time colouring bleaches as a result of decarboxylation of diacetic acid and transformation of it in an acetone. At heating a reaction has considerably more rapid motion.

Motion of work: in two test tubes they pour urines (healthy man and patient with saccharine diabetes) for 2 ml, then add on drops a 10% solution of chloric iron to stopping of formation of sediment of phosphates. Sediment is filtered. To the filtrate they add a few drops

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of FeCl3 and look after appearance of the cherry colouring in a test tube with urine of patient.

Clinical-diagnostic value: with urine of healthy man 20 - 40 mg/day of ketone bodies is excreted. Hyperketonaemia and ketonuria is observed at diabetes melitus, starvation, deficit of carbohydrates in a feed, disorders of gastrointestinal tract, over-producing of hormones - antagonists of insulin (corticosteroids, thyroxine, hormones of front particle of hypophysis and other). The decline of concentration of ketone bodies does not have clinical value. In early child's age the protracted disorders of GIT (toxicosis and dysentery) can cause ketonaemia as a result of chronic starvation and exhaustion.

5.5 Qualitative reactions on bilious pigments 5.5.1 Gmelin’s test.Principle of method: the test of Gmelin on bilious pigments is

based on ability of bilirubin and biliverdin easily oxidize with formation of products, painted in a different color (biliverdin – green, bilicyan – blue).

Motion of work: to 20 drops of the concentrated nitric acid in a test tube carefully on a wall is added from a pipette the probed urine so that liquids were not mixed up. Then on merging of two liquids rings, painted in a different color: green, dark blue, violet, red and yellow, appear. First yellow ring appears.

5.5.2 Reaction with alcoholic solution of iodine (the unitized test of Rozin) Principle of method: under the action of iodine bilirubin of urine

is oxidized into biliverdin.Motion of work: they pour 4-5 ml of urine in a test tube and

carefully on the walls of test tube make in layers solution of iodine. Appearance on merging of two liquids of green ring testifies to the presence of bilirubinу.

Clinical-diagnostic value. Bilious pigments (bilirubin, biliverdin and other) appear in urine as alkaline salts at hepatitis. Bilious pigments form from hemoglobin at destruction of red blood cells.

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Test control questions1 With what purpose in a clinic determination of creatinine in blood

and urine is used: a) for clarification of diagnosis; b) for determination of clearence; c) for control after determination of day diuresis; d) for determination of rate of kidney filtration; e) for determination of speed of kidney blood stream; f) for determination of excretory function of kidneys?

2 At what conditions does concentration of creatinine in urine decrease: a) diaseases of liver (necrosis); b) acute infectious myosistis; c) deficit of ATP is in an organism; г) deficit of vitamins (A, С, B, Е); д) disorder of permeability of muscular membrane; е) illnesses of kidneys?

3 How is clearence of different substances estimated in relation to clearence of creatinine: a) if it higher than clearence of creatinine, the probed substance is secreted in canalicules; b) if it lower than clearence of creatinine, substance is reabsorped in canalicules; c) if it higher than clearence of kreatinine, substance is reabsorped in canalicules; г) if it lower than clearence of creatinine, substance is secreted in canalicules?

4 What is purpose of the determination of endogenous creatinine clearence: a) for the diagnosing of reabsorption function of tubu-les; b) for determination of rate of kidney filtration; c) for the esti-mation of amount of functioning nephrones; d) for determination of speed of kidney blood stream; e) for determination of concentration function of kidneys; f) for determination of maximal reabsorption of glucose?

5 Name obligatory researches of blood and urine, which are used for diagnostics of pathologies of kidneys.

6 Explain what laboratory researches are provided for a research the filtration function of kidneys?

7 Give determination of concept “clearence”. Name a testimony and terms of conducting of researches, CDV. Mark, what tests are provided for the estimation of the condition of glomerular vehicle of kidneys?

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8 Describe methods after which reabsorption ability of kidneys can be estimated.

9 Describe laboratory tests after which the functions of tubules of kidneys can be estimated.

10 What pathological or physiological conditions of organism can give a decreasing of filtrational closity.

11 Give examples of diseases with increasesing and decreasing of glomerular filtration and.

12 Name the organospecific enzymes of kidneys. Explain their diagnostic value.

13 Explain principle of method and CDV of determination of transamidase and glutaminase in the blood serum.

14 Name the features of metabolism in kidneys.15 Name factors which influence on rate of glomerular filtration.16 Name the scopes of physiology vibrations of concentration of

kreatinine in blood, factors which influence on them, CDV of index.

17 Represent the graph of dependence of clearence of creatinine from the concentration of creatinine in blood. Give explanation.

18 Explain CDV of determination of urea in the blood serum. Name factors which influence on this index.

19 Name factors which influence on correlation of concentration of urea to creatinine in blood, explain the role of this index.

20 What value does have determination of β2-microglobulin in blood for diagnostics of diseases of kidneys?

21 What changes in the analysis of urine do take a place at violation of functions of tubules of kidneys?

22 What basic changes in the biochemical analysis of blood and urine are observed at acute renal failure?

23 What basic changes in the biochemical analysis of blood and urine are observed at acute glomerulonephritis?

24 What basic changes in the biochemical analysis of blood and urine are observed at chronic glomerulonephritis?

25 What basic changes in the biochemical analysis of blood and urine are observed at the nephrotic form of chronic glomerulonephritis?

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26 What basic changes in the biochemical analysis of blood and urine are observed at chronic renal failure?

27 What basic changes in the biochemical analysis of blood and urine are observed at a acute pyelonephritis?

28 What basic changes in the biochemical analysis of blood and urine are observed at a chronic pyelonephritis?

29 Name reasons of prerenal acute renal failure. Explain changes in the biochemical analysis of blood and urine.

30 Name reasons of intrarenal acute renal failure. Explain changes in the biochemical analysis of blood and urine.

31 Name reasons of postrenal acute renal failure. Explain changes in the biochemical analysis of blood and urine.

32 What biochemical indexes of blood and urine must be controlled at treatment of acute renal failure?

33 Name the metabolic and biochemical consequences of the terminal stage of diseases of kidneys.

34 Explain reasons of development of hypocalciaemia at patients with chronic renal failure.

35 Name the basic clinical symptoms of chronic renal failure. Name the ways of correction of biochemical indexes of blood and urine at treatment of this pathology.

36 What changes in the hormonal background of organism do take a place at chronic renal failure?

37 Name principal reasons of development of proteinurias.38 Make the algorithm of research of proteinurias.39 Represent uroproteinogram at selective proteinurias. Give

explanation.40 Represent uroproteinogram at a nephrotical syndrome. Give

explanation.41 Name principal reasons of nephrotic syndrome. Provide

laboratory diagnostics.42 Name principal reasons of syndrome of Fankoni. Provide

laboratory diagnostics.43 Name principal reasons of kidney acidosis of tubules. Provide

laboratory diagnostics.

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44 Name testimonies for providing of test on acidifying of urine, its methodics, interpret the results.

45 Name factors which cause formation of renal concrements. Explain the clinical value of research of their chemical composition.

46 Choose laboratory tests for the inspection of patients with urolithiasis. Explane the choice.

Analysis of case historyI - P. 75-84, N 4.1-4.4.

Situation tasks1 Sick 12 years. Seven years ago suffered from a acute nephrite. Next 5

years the condition remained satisfactory. Analyses of urine and blood are without rejections. At an inspection for a removal from a clinical account was found out violation of secretory function of kidneys. The level of cholesterol rose to 7,3 mmol/l, urea - 6 mmol/l.

Is it possible to take off this child from an account? What diagnosis can be assumed? What researches of blood it is needed to be provided: 1) fibri-nogen; 2) a general protein with protein fractions; 3) TTG; 4) coagulogram; 5) creatinine , indican; 6) urinary acid; 7) calcium; 8) Reberg’s test; 9) con-centration of protein in day's amount of urine?

2 Sick K., 38 years, hospitalized with the expressed edemas of lower extremities, increased АP, decreased diuresis. During hospitalization, condition of middle permanent, pallor and puffiness of face, edemas in combs, shins, feet. Diuresis - 600 ml. Analysis of urine: turbid, a color is yellow, density - 1020, protein - 5 g/l, leucocytes – 10-12 in the field of sight. Analysis of blood: haemoglobin - 100 г/л, red blood cells - 3,1·1012/l, leucocytes - 16·109/l, SR- 46 mm/h. General protein - 55 g/l, albumen - 40 % (22 g/l), kreatinine - 0,18 mmol/l, urea - 24,5 mmol/l.1 What diagnosis can be assumed: a) cardiovascular insufficiency; b) pneu-

monia; c) sepsis; d) renal failure, sharp nephrite?2 What additional researches need to be provided: a) indexes of pH;

b) electrolytes in plasma; c) clearence of kreatinine; d) osmolarity of plasma; e) activity of enzymes: ALT, AST, creatinkinase; f) cholesterol; g) packed cell volume?

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3 Estimate the results of researches: indexes of: рН = 7,36; рСО2 = 35,2 of m.c.; ВВ=40 mmol/l; SВ=20 mmol/l; ВО=12 mmol/l; concen-tration of K is 5,9 mmol/l, Na - 130 mmol/l; osmolarity - 280 mosm/l; packed cell volume - 0,38; ALT- 0,85 mmol/l, AST- 0,6 mmol/l, creatinkinase - 10 МО/l; clearence of creatinine (glomerular filtration rate) - 67 ml/min.

4 What violation of water exchange and what type of edema take place at patient: a) dehydration; b) hyperhydration; c) membranogen; г) lym-phogen; д) hypodynamic; е) hypoproteinic?

5 Explain the origin of edemata.3 Gather additionally the most informing connection of enzymes for the

inspection of patients with the diseases of a)kidneys; b) pancreas; c) loco-motor apparatus; d) psychical sphere; e) at malignant tumours:1 Amylase. 2 Uropepsinogen. 3 Lipase. 4 Acid phosphatase. 5 ALT. 6 AST. 7 Sorbitoldehydrogenase. 8 Alkaline phosphatase . 9 Glucose-6-phosphatedehydrogenase. 10 Cholinesterase. 11 Lactatdehydrogenase. 12 Isoenzymes of lactatdehydrogenase. 13 Trypsin. 14 Katalase. 15 Krea-tinkinase. 16 Fructose-1,6-diphosphatealdolase. 17 Fructosemonophosphat-ealdolase. 18 Ceruloplasmine. 19 Carboanhydrase. 20 Monoaminoxidase. 21 Acetylcholinesterase. 22 Hexokinase. 23 Arginase. 24 Adenosindes-aminase. 25 Transamidinase. 26 Urokinase. 27 Leucininaminopeptidase. 28 Isoenzymes of malatdehydrogenase. 29 Isoenzymes of alkaline phophatase. 30 Isoenzymes of amylase.

LiteratureI – p. 57-76.

Lesson 12Theme. Disorders of gastrointestinal tract functions, their

diagnostics and diet therapy

Questions for preparation1 Disorders and examination of stomach function. Clinical-diagnotic

value of separate indexes of gastric secretion.2 Examination of pancreas function.3 Examination of intestine function.4 Disorders of intestine function.

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5 Biological role of hormones of gastrointestinal tract.6 Role of vitamins, microelements in a medical diet.

Execute and interpret the results of experiments1 Determination of general acidity, general hydrochloric (HCL)

acid, combined HCL acid and free HCL acid in one portion of gastric juice

Course of work: place in the test-tube 5 ml of the filtered gastric juice, add 1 drop of n-dimethylaminoazibenzolum and 2 drops of phenophthaleinum. At the presence of free HCL acid it turns red in color, at its absence there appears a yellow or an orange colouring. Titrate free HCL acid by 0,1n solution of meadow from a burette before the appearance of the orange colouring and write down the result (1-st mark). Not adding a meadow to the burette, continue titration before the appearance of a lemon-yellow color and write down the result (2-nd mark). Continue titration before the appearance of the rose colouring (3-rd mark).

Calculation: 1-st mark shows the amount of free HCL acid; 3-rd shows the general acidity. Arthimetical mean between 2-nd and 3-rd marks gives the general HCL acid.

Combined HCL acid is determined as the difference between the amount of general HCL acid and free.

For example, if such amount of 0,1 n of Na(OH) is spent in titration:

1-st mark – 1,6 ml;2-nd mark – 1,8 ml;3-rd mark – 2,4 ml, free HCL will be evened 32 mmol/l, general acidity – 48 mmol/l, general HCL – 1,8 + 2,4 1000 · 0,1

· = 42 mmol/l 2 5 Combined HCL – 42-32 = 10 mmol/l.

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Clinical-diagnostic value. Normal values: general HCL acid – 40 - 60 mmol/l, combined HCL acid – 2-15 mmol/l and free HCL acid – 20-40 mmol/l, general рН=1,5-2,5 units.

Determination of gastric juice acidity is important for the diagnostics and correct choice of treatment methods in some stomach and duodenum diseases. For patients with a duodenal ulcer, and also with hyperacidic gastritis, there is an increase of free HCL acid (hyperacidity) and general acidity (hyperaciditas). Decreased amount of free HCL acid (hypoacidity) and general acidity (hypoaciditas) is characteristic for a chronic atrophic gastritis. Hypoacidity, inacidity, achlorhydria (complete absence of HCL acid and pepsin) is seen in patients with stomach cancer .

2 Quantitative determination of uropepsin in urine Clinical-diagnostic value. 1 ml of gastric juice contains 40 -

60 units of activity (UA) of pepsin. In one day with urine there is an excretion of 150 - 300 UA of uropepsinogen or 1,5 - 3 mg. In achlorhydria pepsin in gastric juice and uropepsin in urine can be absent. At ulcerous diseases the amount of pepsin is sharply increased.3 Pathological components of gastric juice and their exposure

Note.

Write results in a table and make a conclusion

Number of test tube

Pathological component of gastric juicelactic acid blood bilious pigments

3.1 Exposure of lactic acid by the qualitative reaction of Uffelman.

Principle of method: lactic acid at presence of phenolate of iron (violet), forms the lactate of iron of yellow-green color.

Course of work: to the reagent Uffelman (20 drops of a 1% solution of phenol + 2 drops of a 1% solution of chloric iron) add 5 drops of gastric juice. Watch the formation of a yellow-green color (lactic iron).

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Clinical-diagnostic value. Lactic acid is excreted by microflora with lactic acid fermentation in stagnation or in the absence of free HCL acid, and also as a product of cancer cells metabolism. Portions of gastric contents are examined with the presence of lactic acid, gotten on an empty stomach.

3.2 Exposure of blood in gastric juicePrinciple of method: at the presence of blood in gastric juice,

peroxidase (acceptor of electrons of H2O2), oxidizes benzidine with the formation of a dark blue colour.

Course of work: to 5 drops of a 1% solution of benzidine, add 5 drops a 3% solution of H2O2 and 5 drops of the probed gastric juice. At presence of blood watch the formation of the dark blue colouring.

Clinical-diagnostic value. Blood can get in gastric juice at bleeding from the walls of stomach, from the varicose extended veins of gullet, at pulmonary bleeding, and also with meals.

3.3 Exposure of bilious pigmentsPrinciple of method: bilious pigments in the presence of

concentrated nitric acid are able to form merging of two liquids the coloured rings in such sequence: green, dark blue, violet, red, red-yellow. A reaction makes possible to find out bilirubin in solution 1: 80000.

Course of work:1st method. In a test tube put in 1 ml of the concentrated nitric acid

and carefully add the probed gastric juice. Watch the formation of the coloured rings on the union of liquids.

2nd method. On the filtration paper drop the gastric juice, wait and then on the middle of spot drop the concentrated nitric acid which contains a bit of nitrous acid. Watch for the appearance of the coloured rings.

Clinical-diagnostic value. Bilious pigments (bilirubin, biliverdin) can get in gastric contents as a result of antistalsis of intestine. The presence of bilious pigments predetermines the characteristic of grassy green or yellow color of gastric contents.

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4 Determination of amylase activity in the blood serum and urine by the Caraway method

Principle of method: this method is based on a colorimetery of undivided starch by its intensity after colouring with iodine. One unit of hemodiastase is the amount (in mg) of the starch, hydrolysed by 1 ml of serum in 1 hour.

Course of work: work is executed in volumetric flasks (50 ml), which are filled in accordance with the following table:

Reagent Working test, ml

Experimental test, ml

Starched substratum 5 5Incubation in the thermostat (5 min at 37°С)Blood serum - 0,1Interfusion, incubation in the thermostat (7,5 min at 37°С)Blood serum 0,1 -Solution of iodine 5 5To the volume of reactionary mixtures in test tubes add distilled

water (to 50 ml) and at once measure extinction of solutions at a red colour filter (wave-length 630- 90 nm) in a cuvette (10 mm) against the distilled water (control).

Calculation:Er- Ed

Dk = · 2 · 80 Er Where,Dk is a diastase of blood (mg/ml · hr, or g/l · hr);Er is extinction of working test;Ed is extinction of experimental test;2 is the amount of starch, contained in working and experimental tests, mg;80 is the coefficient of count on 1 ml of serum and 1 hr incubation.

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Clinical-diagnostic valueNormal values. Blood serum: 3,3-8,9 mg/(sec·l), or 12-

32 mg/(hr·ml). Urine: to 44 mg/(sec·l), or 120 mg/(hr·ml). Duodenal contents: 1,7-4,4 g/(sec·l), or 6-16 g/(hr·ml). Coefficient of count in SI units - mg/(sec·l) – 0,278.

Considerable increase: acute pancreatitis (in 5-10 times), decrease of glomerular filtration rate, severe diabetic ketoacidosis. Moderate increase: syndrome of acute stomach (peptic ulcers, hepatic gripes, impassability of bowels, acute appendicitis, abdominal trauma, peritonitis); disease of salivary glands (epidemic parotitis, stone in the salivary gland or its channel); diabetic ketoacidosis, acute alcoholic intoxication, uremia, burns.

Chemical and pharmacological interference. Increase of activity: corticosteroids, narcotic analgesics, salicylates, tetracycline, furosemide, histamine, secretin, peroral contraceptives, sulfanil-amides. Decrease of activity: oxalates, citrates, pyruvate.

Control questions1 Name the functions of gastrin and regulation of its secretion.2 Name a testimony to the leadthrough of pentagastrine test,

describe the method of leadthrough, interpret results in a norm and at pathology.

3 Explain how secretion of HCl changes for patients: with ulcerous illness of duodenum, with ulcerous illness of stomach, with a atrophicgastritis

4 Explain how secretion of HCl changes for patients: with ulcerous illness of duodenum, with carcinoma of stomach, with pernicious anaemia.

5 Explain how secretion of HCl changes at a stomach and selection a gastrin on introduction of secretin and albuminous diet at: syndrome of Zollinger-Ellison, pernicious anaemia, to the hypersecretion of gastrin by antral G-cells.

6 Name factors and pathological processes which promote or reduce a gastric secretion. Mark Clinical-diagnostic value of determi-nation of volume of gastric secretion.

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7 Mark Clinical-diagnostic value of determination of рН of gastric juice.

8 For the estimation of gastric acidity determine the debit of HCL of basal secretion and maximal secretion. What these indexes in a norm, at ulcerous illness of duodenum, syndrome of Zollinger-Ellison.

9 What pathological processes do accompany an increase and decline of secretion of HCl in a stomach?

10 Explane clinical-diagnostic value of determination of fermentative activity of gastric juice. Name pathological processes in an organism at which the fermentative function of stomach rises or goes down.

11 Choose laboratory tests for diagnostics of diseases of stomach.12 Choose constelation of laboratory tests for diagnostics of diseases

of thin and thick bowels.13 Choose laboratory tests for diagnostics of chronic gastritis, specify

on changing of the chosen indexes.14 Choose laboratory tests for diagnostics of ulcerous illness of

stomach, specify on changing of the chosen indexes.15 Choose laboratory tests for diagnostics of cancer of stomach, mark

the change of the chosen indexes.16 Describe the method of secretin-cholecystokinin test, interpret a

result in a norm and at pathology.17 Describe direct tests which is used for description of exocrine

function of pancreas, explain their essence.18 Describe not direct tests which used for description of exocrine

function of pancreas, explain their essence.19 Explain principle and method of leadthrough of test from

dilauratum fluorescinum. Interpret a result in a norm and at pathology.

20 Choose laboratory examinations which must be appointed at the diseases of pancreas. Argue the choice. Select basic and additional tests.

21 Choose the most informative tests for diagnostics of syndrome of cytolysis of pancreas. Specify on changing of indexes.

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22 Explain what changes in a biochemical analysis of blood and urine take place at the syndrome of incretory pancreas insufficiency.

23 Choose laboratory examinations which must be appointed at diagnostics of acute pancreatitis, at monitoring of treatment.

24 What changes are there in a biochemical tests of blood, urine, pancreatic juice at cancer of pancreas?

25 Describe a situation at which there is a decline of ammount and debit of bicarbonates at normal or enhanceable activity of enzymes of pancreas.

26 Describe a situation at which there is a decline of ammount and debit of secretion of pancreas.

27 Name pathological processes in an organism, which lead to hyperamylasaemia, hypoamylasaemia.

28 Explain what clinical diagnostic value the examination of coefficient inhibitor of trypsin/trypsin has for diagnostic of diseases of pancreas has.

29 Conduct laboratory diagnostics of chronic enterocolitis.30 Choose laboratory tests for establishment of diagnosis of

malabsorption. Specify the changes of the chosen indexes.31 What biochemical tests for differential diagnostics of different

forms of malabsorption are used?32 Explain principle of method, condition of leadthrough,

interpretation of results, diagnostic value of test of absorption of xylose.

33 Explain principle of method, condition of leadthrough, interpreta-tion of results, diagnostic value of respiratory test from C-14-trioleinum. At whatever diseases does not a test from C-14-trioleinum give reliable results?

34 Explain the principle of method, condition of leadthrough, interpretation of results, diagnostic value of respiratory test from C-14-xylose.

35 Describe the biological role, signs of insufficiency, methods of diagnosing vitamin B1 deficiency.

36 Describe the biological role, signs of insufficiency, methods of diagnosing vitamin PP deficiency.

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37 Describe the biological role, signs of insufficiency, methods of diagnosing vitamin B12 deficiency.

38 Describe the biological role, signs of insufficiency, methods of diagnosing vitamin C deficiency.

39 Describe the biological role, signs of insufficiency, methods of diagnosing vitamin A deficiency.

40 Describe the biological role, signs of insufficiency, methods of diagnosing vitamin D deficiency.

41 Describe the biological role, signs of insufficiency of vitamins K and E.

42 Describe the biological role of zinc, reason of its insufficiency.43 Describe the biological role of copper, signs of insufficiency and

excess.44 Describe the biological role of selenium, signs of insufficiency,

methods of diagnosing insufficiency.45 What laboratory examinations are conducted at parenteral feed

and its complications?46 What changes in a biochemical blood test arises up at the general

nutritional insufficiency?47 Choose laboratory examinations for control of the state of the

exhausted patients.

Analysis of case historyI - P. 113, N 6.1; P.119-121. - N 6.2-6.4; P. 339.- N 21.1; P. 341. - N 21.2.

Fill in a table “Tests of functional activity of gastrointestinal tract and their interpretation” (that contains such columns: department of gastrointestinal tract, tests on determination of function, purpose of test, result in norm, changes under pathologies, additional examinations).

LiteratureI – p. 95-108, 315-324.

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Lesson 13Theme. Laboratory diagnostics of the inherited metabolic diseases.

Features of clinic-laboratory diagnostics of diseases of extreme age. Biochemical aspects of pregnancy and early child's age

Questions for preparation1 Influence of mutagenic factors on structure of the genome,

adjusting of its transcription and translation.2 The horizontal and vertical passing to heredity and transformation

of its violations in a disease.3 Anomalous metabolic processes in organs and tissues of organism

and biochemical tests for diagnostics of the inherited pathologies.4 Inherited violations of exchange of carbohydrates, their clinic-

laboratory diagnostics.5 Inherited violations of exchange of lipids, their clinic-laboratory

diagnostics.6 Inherited violations of protienmetabolism their clinic-laboratory

diagnostics.7 Prenatal diagnostics of the inherited metabolic diseases.8 Possibilities of genetic analysis in diagnostics of the inherited

metabolic diseases.9 Biochemical principles of treatment of the inherited metabolic

disturbances.10 Metabolism of carbohydrates, hormones, proteins, lipids during

pregnancy, for newborn children, for children and old people.11 Question of norm of biochemical indexes for geriatric patients and

children.12 Screening programs for children and old people.13 Illnesses of child's age, features of their laboratory diagnostics.14 Illnesses of old people, features of their laboratory diagnostics,

interpretations of results.15 The pregnant and babies laboratory examinations.

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Execute and interpret the results of experiments1 A qualitative reaction on phenyl-pyruvic acid (PPK)

Principle of method: phenyl-pyruvic acid forms with the ions of trivalent iron complex connection, stained in a blue-green color.

Course of work: to 2 ml of the filtrated urine pour 8-10 drops of a 10% solution of FeCl3. At presence in urine of phenyl-pyruvic acid the blue-green colouring which gradually fades through appears in about 30-60 sec to 5-30 min depending on the concentration of phenyl-pyruvic acid in urine. This test can be done on a filtration paper: the strip of filtration paper is moistened with urine, dryed out on air and inflicted with a drop of 10% FeCl3. A positive test gives the blue-green colouring.

Clinical-diagnostic value. A reaction is positive at innate insufficiency of enzyme of 4-phenilalaninhydroxylase (phenyl-pyruvic oligophrenia).

2 A qualitative reaction on mucopolysaccharides (test of Berri and Spinanger)

Principle of method: at cooperation of MPS with tolouidine the red colouring appears in an acidic environment dark blue (metachromasia).

Course of work: on the strip of filtration paper in the distance inflict 1 cm one from another: 0,005; 0,01; 0,025 ml of urine. Dry up the strip at room temperature; dip in a 0,04% solution of tolouidine dark blue for 1 min. Take out the strip and wash 10% CH3COOH. The red colouring appears during the concentration of MPS of more than 10 mg/100 ml.

Clinical-diagnostic value. Contents of mucopolysaccharides increase in mucopolysaccharidoses (MPS), including the syndrome of Morkio (MPS of IV type), diseases of kidneys whith mucoproteinuria, the damages of connective tissue are expressed (especially in rachitis, sprue with osteomalation, malignant tumours with vast metastasis, systemic lupus erythematosus, for some patients by pseudorheumatism or the Marfan’s syndrome).

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Pharmacological interference. Increases the level of mucopo-lysaccharides: heparin, phenitoinum, penicillinum (for some patients).3 Determination of creatinine in urine of children and old

people Principle of method: creatinine reacts with picric acid in an

alkaline environment with formation of red tautomere of picrate to the creatinine which predetermines appearance of the proof orange-red colouring. Intensity of colouring is proportional to the concentration of creatinine.

Course of work: test tubes are filled in accordance to the table.Reagent Test (ml)

experimental standard controlDistilled water, ml - 2,0 -Working standard solution of creatinine, ml

- 1,0 -

Solution of TCA acid, ml - 1,0 -Mix up, centrifugate 5 min at 3000 rpm. Before an analysis urine is conducted in 100 times (to 1 ml of urine add 99 ml of dist. water).Free liquid, ml - 2,0 -Urine divorced, ml 1,0 - -Solution of TCO acid, ml 0,5 - 0,5Distilled water, ml 0,5 - 1,5Solution of picrine acid, ml 1,0 1,0 1,0NaОН –10%, ml 1,0 1,0 1,0Mix up, leave for 20 min at a room temperature, photocalorimeter against control at 500-560 nm in a cuvette with the thickness of layer 1сm

The calculation of concentration of creatinine (C) is conducted after a formula Eexp Eexp

SC = 2 · mg% or C = 177 · μmoll/l Estand Estand

where С is contents of creatinine in a test, mg% (μmoll/l);2,0 (177) is an experimental concentration of creatinine;Eexp is an absorbancy of experimental test;Estand is an absorbancy of standard test.

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Clinical-diagnostic value. Secretion of creatinine with urine increases (hypercreatineuria) at the consumption of meat meal, squashing of soft tissues (muscles), intensive muscular work, by the removal of bloodstopping plait, fever, pneumonia.

Content of creatinine decreases in urine (hypocreatinuria) at chronic nephritis with uremia (to kidney insufficiency), muscular atrophy, degeneration of kidneys, leukemia, at old people.

Clinical and chemical interference: clinical growth is predetermined by nephrotoxic medicines. Increase of creatinaemia, predefined by chemical influence, give bromsulfophtaleinum, phenolsulfophtaleinum, acetic acid, ascorbic acid, levodopa, methyldopa, glucose, fructose.4 Determination of indican in urine of children and old peole

Clinical-diagnostic value. Indicanaemia is the early symptom of renal faliure insufficiency. The increase of contents of indican in the blood serum is observed in most cases of glomerulonephritis. The content of indicane increases at chronic nephropathies, nephrosclerosis with the phenomena of corrugation of kidney.

A positive reaction on indican is observed during strengthening of putrid processes in bowels: at their impassability, volvulus, locks, and also at tissue disintegration and breaking up of proteins (abscesses, sepsis, tumours and others like that).

In norm, content of indicane in blood – 0,87-3,13 μmoll/l. In urine it is contained in negligible quantities and does not appear at qualitative tests.

Control questions1 Explain reasons of origin of hepatomegalia, acidosis, bleeding at

the inherited insufficiency of glucose-6-phosphatase.2 Make the algorithm of examination of hypoglucosemia for

establishment of diagnosis glycogenosis of I type.3 Choose the most rational laboratory tests for diagnostics of the

inherited insufficiency of glucose-6-phosphatase.4 Explain the development of hypoglucosemia at a glycogenosis of

type I.

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5 Name reasons of origin and clinical consequences of galactosaemia.

6 Choose laboratory tests for establishment of diagnosis of galactosaemia for children with the clinical manifistations of this disease.

7 Name the changes of biochemical indexes of blood and urine, which are observed at galactosaemia.

8 Name reasons of origin, clinical manifistations of phenylketonuria.

9 Describe the methods of laboratory diagnostics and methods of correction of phenylketonuria.

10 Schematically represent violation of exchange of steroids at insufficiency of 21-hydroxylase.

11 Describe laboratory diagnostics of mucoviscidosis.12 Name a testimony for the leadthrough of screening of new-borns.13 Name a testimony to prenatal diagnostics.14 Describe the methods of prenatal diagnostics. Name the most

ponderable, argue with the answer.15 Mark the diagnostic value of analysis of amniotic liquid or cells

amnion in a culture, got by puncture of fruit bubble. Notice, what the risk of such manipulation must be correlated with.

16 Mark the diagnostic value of analysis of the got standard of chronic cilia. Notice, what the risk of such manipulation must be correlated with.

17 Name genetic pathology which is reason of such clinical picture: heavy glucopenia, hepatomegalia, lactoacidosis, lipidemia, hyperuricemia, accumulation of hepatin in thrombocytes. Explain biochemical reasons of such clinical picture.

18 Name the biochemical criteria of diagnostics of deficit of glucose-6-phosphatase.

19 Describe clinical symptoms of deficit of galactose-1-phosphateuridylltransferase.

20 Describe biochemical violations which arise up as a result of deficit of phenilalaninhydroxylase.

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21 Describe clinical symptoms of insufficiency of 21-hydroxylase steroids.

22 Name reason and basic clinical symptoms of mucoviscidosis.23 Describe clinical symptoms, biochemical violations and laboratory

diagnostics of alkaptonuria.24 Describe main clinical symptoms, biochemical violations,

laboratory diagnostics of homocystinuria.25 Describe clinical symptoms, biochemical violations, diagnostics

of cystinosis.26 Name the clinical displays of defects of cycle of urea. Describe

the complex of laboratory indexes determination of which is expedient at suspicion on violation in the urea cycle.

27 Describe prenatal diagnostics of mucoviscidosis.28 Describe using of restrictases and probes of DNA for a genetic

analysis.29 What requirements are pulled out to screening examinations of

genetic illnesses?30 Explain the role of polymerase chain reaction in the genetic

analysis of the inherited diseases.31 Give examples of diseases, strategy of treatment of which is based

on limitation of receipt substratumу. Explain an answer.32 Give examples of diseases, strategy of treatment of which is based

on entered absent product. Explain an answer.33 Give examples of diseases, strategy of treatment of which is based

on additional introduction of vitamin cofactors. Explain an answer.

34 Give examples of diseases, strategy of treatment of which is based on strengthening of egestion of toxic products. Explain an answer.

35 Give examples of the inherited diseases at which there increase concentration of aminoacid in blood and urine. Explain an answer.

36 Name basic groups and mark the general signs of gangliosidoses.37 Name the functions of organism of man, which change with age.38 Name a disease, that is peculiar for geriatric patients.39 Name problems which arise up for doctors and clinic biochemists

at an inspection and treatment of geriatric patients.

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40 Name laboratory indexes which change with age.41 Describe principles of establishment of norm of biochemical

indexes for people of senior and elder years. Name these indexes.42 Describe and compare motivation of the screening programs of

diseases for young people and geriatric patients.43 Describe passing of diseases, their symptomatics and

complication for geriatric patients.44 Name screening biochemical tests for the people of senior age.

Give explanation.45 Describe and compare problems into which a clinical biochemist

runs at the inspection of children and old people.46 Name matters, the values of concentrations of which in blood of

children differ from normal values for adults.47 Name causes and effects of hypoglucosemia in new-born.48 Name causes and effects of hypocalciaemia and hypomagnesemia

in new-born.49 Explain the features of diagnostics of jaundice of newborn.50 Name circumstances at which it is necessary to conduct examination of neonatal jaundice.51 Name reasons of hyperbilirubinemia with unconjugated bilirubin

in newborn.52 Name reasons of hyperbilirubinemia with conjugated bilirubin in

newborn.53 Give a testimony for the leadthrough of screening examinations

in newborn.54 Name screening tests for metabolic violations in newborn.55 Name causes of hyperamoniaemia in early child's age and their

effects for an organism.56 Name the possible reasons for insufficient increase of mass and

dysplasia in newborn. Explaine the role of laboratory examinations for the establishment of diagnosis.

57 Name reasons for violation of sexual differentiation and pathological sexual ripening.

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58 Name reasons of premature and pseudopremature sexual ripening of children, mark the role of laboratory examinations for the establishment of diagnosis.

59 Name reasons of late sexual ripening of children, mark the role of laboratory examinations in establishment for the diagnosis.

60 Describe the basic changes of biochemical indexes exchange of proteins and carbohydrates in the organism of woman during pregnancy.

61 Describe contest of hormonal backargue of organism of woman and the changes of metabolism which they related to it.

62 What laboratory examinations do we appoint for control of the state of pregnancy?

63 Name the features of laboratory control of pregnancy in women with diabetes mellitus.

64 Name the features of laboratory control of pregnancy in women with high blood pressure.

65 Describe the features of hormonal backargue in newborn.66 Describe the adaptation changes of the respiratory system in new-

born. Name reasons for possible violations.67 Describe the adaptation changes of function of kidneys in new-

born. Name reasons for possible violations.68 Describe the adaptation changes of liver function in newborn.

Name reasons for possible violations.69 Describe the adaptation changes of digestive system in newborn.

Name reasons for possible violations.

Analysis of case historyI - P. 209.- N. 11.8; P. 353.- N. 22.5.Fill in the table of “Inherited metabolic diseases”, which would contain such columns: type of exchange, name of pathology, molecular reason, change of pathological indexes of blood and urine, methods of diagnostics, clinical manifistations.I – P.168 – 9.1; P. 228 – 12.5; P. 349-354 – 22.1-22.6.

LiteratureI – p. 251-264, 265-276, 325-333.

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Lesson 14Theme. Biochemical indexes at oncologic diseases. Clinical-

laboratory diagnostics of the cardio-vascular system, connective tissue, breathing organs diseases

Questions for preparation1 Genetic basics of proliferation.2 Mechanisms of regulation of inherited information transfer and

their violation.3 Hypothesis about the origin of malignant growth.4 Paraneoplasticity endocrine syndromes, their laboratory

diagnostics.5 Metabolic complications of oncologic diseases.6 Markers of tumours.7 Role of laboratory examinations is in the exposure of reasons of

development and forms of hypertensive illness.8 Reasons for development and laboratory diagnostics of

atherosclerosis.9 A role of laboratory examinations in diagnostics of diseases of

heart.10 Laboratory tests of the activity of rheumatic process.11 Clinic-laboratory diagnostics for diseases of connective tissue.12 Laboratory diagnostics for diseases of respiratory organs.

Execute and interpret the results of experiments1 Determination of activity of alkaline phosphatase in the blood serum

Principle of method: alkaline phosphatase slits phenylphosphate with formation of phenol and phosphate. A phenol reacts with 4-aminophenasone at the presence of oxidant – periodate of sodium with formation of stained chinonimine. Intensity of colouring of reactionary solution is directly proportional to activity of enzyme.

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Course of work: work is conducted after a table.Reagent Experimental

test (ml)Controltest (ml)

Substratum-buffer solution 2,1 2,1Incubate for 3 min at +370C

Blood serum 0,07 -Incubate for 10 min at +370C

Oxidizing solution 2,1 2,1Blood serum - 0,07Maintain 5 min at a room temperature. Measure the absorbancy of experimental test against control. On PEC at 490-540 nm in a cuvette 1 cm. The calculation of activity of enzyme in the blood serum is conducted by the gauge graph

Clinico-diagnostic valueNormal values:

- men - 900 to 2290 nmoll/sec·l;- women - 740 to 2100 nmoll/sec·l.

A considerable increase is caused by the mechanical jaundice of different genesis, illness of Peget, bone diseases which are accompanied by proliferation of osteoblasts, billiary cirrhosis of liver. Moderate increase: rachitis, osteomalation, osteosarcoma, metastases of tumours in bones, acute and chronic hepatitis, primary hyperparathyroidism, tumours, granulomas, fatty liver.

The decreases of activity is caused by achondroplasia, cretinism, hypovitaminosis C, inherited hypophosphatemia .

Chemical and pharmacological interference. Increased activity: azatioprine, carbasone, androgens, benzodiazepine, imipramin, car-bamasepine, meprobamatum, merkasolilum, nicotine acid, penicilli-num, peroral contraceptives, progestines, sulfates, sulfanilamides, phenothiasines, erythromycinum, estrogens. Reduced: phtorides, oxalates, phosphates, beryllium, salts of zinc, manganese, arsenites, citrates, cyanides, thiosulphates, EDTA.2 Determination of sialic acids in the blood serum

Principle of method: a method is based on the coloured reaction which has motion at heating of sialic acid (N-acethylneuramine) with

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the Hess’s reagent. Intensity of the dark rose colouring depends on the concentration of sialic acids.

Course of work: in centrifuge test tubes 1 ml of 10% solution of TCA acid is added to 1 ml of blood serum. Shake off. After that the test tubes and put in a boiling aquatic bath-house for 5 min and cool. It results in freeing of connections of N-acethylneuramine acid with albuminous part of molecule of glycoproteins. After centrifuging, to 0,4 ml of free liquid add 5 ml reagent of Hess and again boil in a boiling aquatic bath-house during 30 min. Thus appear dark rose colouring. After cooling, photometer on PEC in a cuvette with the thickness of layer 10 mm against water at a green colour filter (540 nm). The obtained value of extinction is multiplied on 1000. An examination result is given in int. units, expressed through extinction.

Clinic-diagnostic value. In norm the size of it varies from 100 to 195 conditional units, that answers contents of sialic acids from 550 to 790 mg/l (0,7g/l N-acethylneuramine acid).

The increase of sialic acids in blood is observed at rheumatitis, tuberculosis, heart attack of myocardium, malignant tumours of bone tissue, cancer of lungs. 3 Determinations of activity of creatine kinase in the blood serum

Principle of method: activity of creatine kinase is proportional to the amount of inorganic phosphorus which appears as a result of acid hydrolysis synthesized an enzyme bridal creatinephosphate. Inorganic phosphorus is determined by the coloured reaction whith the ammonium molibdate.

Course of work: preliminary all of solutions of reagents warm up during 5 min at 37°С. In a test tube bring in 1,5 ml of basic mixture of reagents, 0,1 ml solution of cystein and 0,4 ml blood serum. The content of test tube is carefully mixed and put in a thermostat at 37°С for 30 min. Then add 0,2 ml of solution of TCA, mix by a glass stick and centrifugate at 3000 rpm during 10 min.

A control test is processed the same as experimental; but a serum is added after filling-up solution of TCA acid. From experimental and control tests take away 1 ml of free liquid and pet to other test tubes (accordingly marked) in which there are contained 2 ml of mix-

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ture of solutions for the leadthrough of specific hydrolysis of creatinphosphate, mix and leave in a room temperature for 30 min (duration of hydrolysis of creatinphosphate). After that in each tests tube 0,25 ml of solution of eucogene is added with an interval in 1 min and exactly through 15 min measure extinction of experimental test comparatively with control on PEC at a wave-length 600-700 nm (red colour filter) in a cuvette with the thickness of layer 0,5 cm.

A calculation is conducted by a gauge graph.

Clinical-diagnostic valueNormal values: to 1000 nmolle/(sec•l), or to 6 IU.

Considerable increase: heart attack of myocardium, dystrophy of muscles, traumatic damage of muscles (breaking up), shock and insufficiency of blood circulation.

Moderate increase: heart attack of myocardium, the damage of skeletal muscles, cramp, thyroprivia, alcoholism, disorder of cerebral circulation of blood, trauma of brain, acute mental state.

Pharmacological interference. Increase activity of CK: amphote-ricine, carbenoxolonum, carbamalum, ethanol, compatible introduce-tion of halothanum and succinilcholinum during anesthesia, barbiturates, adenylatecyclase. Reduces: ultraviolet irradiation, oxidants.

4 Determination of seromucoid in the blood serum Principle of method: it is based on a selection of seromucoid

phosphoric-tungsten acid from the chloric filtrate of blood serum and quantitative determination of hexoses in it - by a orcine method. The concentration of seromucoid is calculated by hexoses.

Course of work: temperature in an aquatic bath-house must be exactly 800°С during all the period of heating. In a centrifuge test tube bring in reagents listed in a table.

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Component Experimental test, ml

Control test, ml

Serum 1,0 -Distilled water 1,0 -Mix and flow on a wallPerchloric acid, 6% solution 2,0 -Well mix by a glass stick, abandon on 10 min, centrifuge during 10 min at 3000-4000 rpm. Free liquid carefully gather in a centrifuge test tube.Phosphoric-tungsten acid, 5% solution

2,0 -

Shake off, centrifuge during 5 min, a centrifugate is united, to sediment refillEtanol 96% 2,0 -Shake up, centrifugate during 10 min, a centrifugated liquid is united, to sediment addNaOH, 0,1 n solution 1,0 1,0Orcine reagent 8,5 8,5

Mix, contain in an aquatic bath-house at 800°С exactly on 15 min. This follows to avoid the direct hit of daylight on test tubes. Cool the test tubes in cold water with ice during 5 min. Measure extinction on PEC at λ = 500-560 nm (green colour filter) in cuvettes with the thickness of layer 1 cm comparatively with control.

The calculation is carried out by gauge graph.Clinical-diagnostic value. The concentration of seromucoid in

blood, defined by hexoses, is 0,22-0,28 gms/l.Determination of sialic acids and seromucoid enables us to find

out the changes which come from collagen complexes, above all things at rheumatism. The concentration of glycoproteins grows at inflammatory and dystrophic processes. There is connection between the increase of contents of sialic acids and seromucoid with the acuteness of rheumatic process, this motion, degree of affection of the cardio-vascular system. Foremost methods can find out activity of pathological process. It is often combined increase of contents of α1- and α2-globulines, and joining of increase of gamma-globulins characterizes passing of disease to the chronic phase.

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The concentration of glycoproteins grows at pregnancy and in the first days after births, at introduction of some hormones, for example - epinephrine, at tumour, inflammatory and purulent processes in lungs and white plague, especially in hematogenic-disseminated and fibro-cavernous forms. It is compared with the increase of ESR (erythrocytes sedimentation rate). Assume that glycoproteins accumulate as a result in the insufficiency of circulation of blood. Like it contents of fractions of blood serum changes during the diseases of stomach, liver, bile passageways; especially high indexes during cancer of head of pancreas.

Control questions1 Give determination to a term "paraneoplastic syndromes". Make

examples of two-three such syndromes.2 Name hormones which are secreted by the cells of the АРUD-

system. Give examples of tumours at which often there is an aberrant secretion of hormones.

3 Name hormones which are secreted by unendocrine tumours with the aberrant secretion of hormones.

4 Describe clinical symptomatics and changes of biochemical indexes of blood and urine at an ectopic secretion of ACTH.

5 Describe clinical symptomatics and change of biochemical indexes of blood and urine at the ectopic secretion of antidiuretic hormone (ADH). Name pathologies which it shows up at.

6 Explain the mechanism of origin of hypercalciaemia at malignant tumours.

7 Explain the mechanism of development of renal falure as metabolic complication at oncologic diseases.

8 Name signs and reasons of origin of cancer cachexia.9 Name the factors of pathogenesis at a cancer cachexia.10 Give description to carcinoid tumours.11 Name clinical manifistations and specify the changes of

biochemical processes at a carcinoid syndrome.12 Name the glands of different types of MEN.

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13 Give description to the marker of tumours - α-fetoproteine. Explaine its diagnostic value.

14 Give description to the marker of tumours - carcinoembryotic antigen. Explaine its diagnostic value.

15 Give description to the markers of tumours - paraproteines. Explaine their diagnostic value.

16 Give description to the marker of tumours - human chorionic gonadotropin. Explaine its diagnostic value.

17 Give description to the marker of tumours - Calcitonin. Explaine its diagnostic value.

18 Describe markers which are used for diagnostics of malignant tumours of prostate.

19 Name enzymes which are used as markers of tumours.20 Give description to carbohydrate antigen markers (UA markers).

Explaine their diagnostic value.21 Name the markers of tumours which are used in clinic for

screening and monitoring.22 Name tumours which are diagnosed by the proper markers.23 Name the markers of tumours which are used mainly with a

diagnostic purpose.24 Name the markers of tumours which are used mainly for

monitoring.25 Describe the inherited endocrine syndromes.26 What value for diagnostics of heart attack of myocardium (MI) do

enzyme decision have?27 What factors do influence the indexes of activity of creatine

kinase?28 What interval of time does activity of CK rise through from the

moment of anginal attack, AST, LDH1?29 When is it recommended to probe lipids after development of

heart attack of myocardium?30 What changes of carbohydrate metabolism are characteristic for

MI?31 How does the level of Na and K change at MI?

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32 What influence on a cell is rendered by the products of lipid peroxidation, that accumulate at MI? What indexes of lipid peroxidation are determined in laboratory?

33 What examinations do have a greater diagnostic value at MI: electrocardiography or determination of activity of enzymes? Give explanation.

34 What are the risk factors of IHD: a) lipidemia; b) obesity; c) hypodynamia; d) high blood pressure?

35 Activity of what enzymes is determined in the first turn at MI: a) creatine kinase; b) AST; c) LDH; d) cholinesterase?

36 What indexes do have a most diagnostic value at IHD: a) general cholesterol; b) triglycerides; c) signing-relation of apoproteines B and A; d) phosphotides?

37 The table of contents of what hormones is increased at MI: a) glucocorticoids; b) catecholamines; c) aldosterone d) thyroxine?

38 What changes of proteinmetabolism are characteristic at MI: a) decline of level of total proteins; b) diminishing of contents of proteins; c) increase of γ2-globulines; d) increase of β-globulines?

39 What factors cause assist development of thrombosis: a) increase of level to the serotonin; b) strengthening of secretion of catecholamines; c) violation of synthesis of prostaglandines; d) change of morphology of thrombocytes?

40 Through what interval of time from the beginning of pain attack the increase of Mb is marked at 100 % of patients:

a) 3 h; b) 1 days; c) 5—9 h; d) 6 h?41 What methods determine of activity of MB-CK: a) chemical;

b) electrophoresis; c) by a sorptography; d) immune inhibition?42 What changes of total analysis of blood are observed for patients

with MI: a) leucocytosis; b) increase of ESR; c) a change toward young forms; d) decline of Hb?

43 Explaine the place of laboratory examinations in diagnostics of hypertensive illness.

44 Choose the most informing laboratory tests for establishing the forms of hypertensive illness. Give examples.

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45 Choose the most expedient laboratory tests of blood and urine, mark their change at hypertension, which arose up on a backargue of Kon’s syndrome.

46 Choose laboratory tests for early diagnosis of atherosclerosis. Explane the choice.

47 Choose laboratory tests, marking their change for establishing the intensity of atherosclerotic process in an organism.

48 Name the laboratory analysis of blood and urine, which the necessary for hearts at ischemic illness.

49 What laboratory tests and for what it is possible to appoint for establishing the diagnosis of ischemic heart disease.

50 Choose laboratory tests for differential diagnosis of heart attack of myocardium and stenocardia. Give explanation.

51 Choose laboratory tests for diagnosis of heart attack of myocardium. Specify changes of indexes in the dynamics.

52 Explaine the changes of metabolism that take place in an organism with heart attack of myocardium? How does it influence on the biochemical indexes of blood and urine?

53 What laboratory tests and for what does appoint at myocarditis?54 Conduct the differential enzyme test for diagnosis of heart attack

of myocardium and myocarditis.55 Mark, what changes in the laboratory indexes of blood are

observed for patients with the different forms of myocardiopathy.56 Name laboratory tests which are used for the estimation of activity

of rheumatic process.57 Represent the electrophorogram of blood serum proteins in acute

phase of rheumatic process. Give explanation.58 Represent the electrophorogram of blood serum proteins which

represents passing of acute rheumatic process to chronic.59 Name laboratory examinations which are obligatory for

establishing the activity of rheumatic process.60 Name laboratory tests which have the indexes of disorganization

of connecting tissue.

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61 Choose laboratory examinations which must be appointed for the diagnostics of diseases of connective tissue, monitoring the treatment. Explain the choice.

62 Name laboratory tests which are obligatory for diagnostic of diseases of connective tissue and which is possible to use as additional for determination of diagnosis.

63 What laboratory examinations and for what does appoint of breathing diseases of organs? What from their are obligatory which additional?

64 Explaine what changes of biochemical indexes of blood take place in patients with infectious dependent bronchial asthma.

65 What laboratory examinations must be appointed for the exposure of dishormonal mechanism of bronchial asthma?

66 Name laboratory examinations which must be appointed for diagnostics of acute pneumonia.

67 Describe the change of biochemical indexes of blood and urine for patients with acute pneumonia in the period of the expressed clinical picture.

68 Represent the electrophorogram of blood proteins at acute pneumonia on the peak of disease.

69 Explain the clinical value for determination of the activity of LDH, ceruloplasmin, amounts of copper at acute pneumonia.

70 Describe the change of ionic composition of blood for acute pneumonia. Explain the reason of this changes.

71 Explaine what laboratory examinations must be appointed at thromboembolia of pulmonary vessels.

72 Choose the triad of laboratory tests, specify on their changing for diagnostics of thomboembolia of pulmonary vessels.

73 Conduct the differential enzyme diagnostics of heart attack of myocardium and thromboembolia of pulmonary vessels.

74 What laboratory examinations must be appointed at respiratory insufficiency? How to interpret results?

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75 Fill in the table of “Paraneoplastic syndromes at oncologic diseases”, which would contain such columns: name of syndrome, reason of origin, change in metabolism, marker, example of malignant disease.

Analysis of case historyI - 19.1 -19.4, P. 311-317, P. 270.- N 15.1, 15.2

Situation tasks1 Patient 30 years. Three weeks ago was ill on a quinsy. Complains pain

in head , weakness, pains in joints, increase of temperature to 39,5°С. Joints at palpation are sickly. Peripheral lymphonodes are a bit megascopic. A liver comes forward from under a costal arc on 3 cm, spleen - on 2 cm. Haemoglobin is 60 gms/l, leucocytes - 3,2 • 109 (eosinophiles - 3%, p - 14%, s - 62%, lymphocytes - 19 %, monocytes - 2 %), ESR - 38 mm/hr. Bilirubin - 28 μmoll/l; total protein is 68 grammes/l, albumen - 38%; globulins -62% (α1 - 47,2 %; α2 - 15 %; β - 15,7 %; γ - 22,1 %). Fibrinogen is a 1 gramme/l; С-reactive protein +++. Volume of antitrypsinolysin - 326 units, antistreptogialuronidaze - 875 units. An urea is normal.

What symptoms does the patient have with rheumatitis? What diagnosis can be assumed?

2 Patient I. was hospitalized with complaints on pain in sternum area, sudden weakness, sweat, sense of fear, dizziness.

It was discovered at examination of enzymes: activity of AST, LDH - insignificantly enhanced. What diagnosis can be assumed: 1) heart attack; 2) stroke; 3) infarction in lungs; 4) stenocardia? What enzymic tests must be executed for determination of diagnosis: 1) creatine kinase; 2) aldolase; 3) cholin-esterase; 4) alkaline phosphatase; 5) isoenzymes of LDH; 6) isoenzymes of CK?3 Patient is 63 years old. Hospitalized with complaints on pain in the counter-clockwise half of thorax, shortness of breath at a state of rest. In a clinic on next day after hospitalization: lost consciousness suddenly. AP (arteriotony) is 80/50 mm of hg. A pulse is threadlike, tones of heart are deaf. On ECG there are no changes. Results of analyses: CK - 12μmoll/(min•l) (norm 0-6); AST – 60 μmoll/(min•l) (norm 2-20); LDH - 15 μmoll/(hr•ml) (norm 0,8-4); leucocytes of blood -12500.

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What diagnosis can be assumed? What is the tactic the doctor should use n the case?

4 Patient 53 years old is delivered in a hospital by ambulance with a diagnosis: acute heart attack of myocardium. Complaints: pains in the area of heart in a state of rest, acute weakness squeezing. Suffers from hypertensive illness during 10 years. Last two days had pains behind sternum, head pains, weakness. On ECG there is an ischemia at an area in front of lateral and back walls. Results of analysis: concentration of glucose in blood - 8,5 mmol/l; AST - 25 μmoll/(min•l) (norm 2-20); leucocytes-8500; hemogram is without changes; ESR - 12 mm/hr.

What additional examinations must be conducted and what diagnosis can be assumed?

LiteratureI – p. 287-300.

Lesson 15Theme. Conclusion session

Situational problems 1. A patient is 22 years old. He has been ill for several months. Subfebrile temperature.Cervical lymph nodes are considerably enlarged, and of thick consistency. Liver snd spleen are not enlarged. Inconsiderable anemia. Leucogram is without particular changes. Erythrocyte sedimentation rate (ESR) is 45 mm/h. Total protein is 90,4 g/l; albumins – 49%; globulins α1- 4 %; α2 – 15%; β – 10%; γ - 22 %. What diagnosis can be assumed? What subsidiary examinations must be made to make the diagnosis accurate?

2. What are the most typical changes in proteinograms observed with patients ill for carcinoma of lungs and how quickly are they detected?

3. A patient with acute pancreatitis. Total protein is 58 g/l. Hypo-albuminemia is detected with increased fraction of β- and reduced α-globulins. How quickly does the changes in the albumins spectrum of blood occur? How can their reliability be checked? Can they be made a criteria for prognosis?

4. 16-year-old patient. Rheumatic disease. Cardiac muscle form. Mitral valve insufficiency. Malignant, progressive flow. Give an approximate proteinogram, received before beginning of glucocorticoid treatment and after it.

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5. 42-year-old patient. Poor condition. Pale, slurred, persistent pains in bones; weakness. Malfunctions of both kidneys were detected. Hemoglobin – 56 g/l, leukocytes – 6,7∙109 (neutrophils, stabs are increased in number). Erythrocyte sedimentation rate (ESR) – 70 mm/h. Total pro-tein – 76 g/l, creatinine – 0,44mmol/l. Discharged from hospital with the diagnosis of chronic nephritis, without improvements, Two months later he admitted into another hospital with acute pain in bones. The patient was additionally examined. In his blood analysis were detected: leukocytes – 4,4∙ 109; myelocytes – 1,5%; metamyelocytes – 4%; eosinophils – 4%, basophils – 0,5%; stabs – 17,5%; segmented neutrophils – 29%; lymphocytes (l) – 39%; monocytes (m) – 4%; plasmocytes – 5%. With the help of electrophoresis of plasma proteins M-gradient was detected.

What mistake was made during the first examination of the patient? What diagnosis was made? Did the data of blood examination help to make the right diagnosis without paracentesis of marrow?

6. 30-year-old patient. Three weeks ago she had angina. Complains of headache, weakness, joint pains, high temperature (to 39,5 °С). Joints are painful for palpation. Peripheral lymph nodes are slightly enlarged. Liver protrudes out under the costal margin at 3 cm, spleen – at 2 cm.

Hemoglobin – 60 g/l, leukocytes - 3,2 ∙ 109 (eosinophils – 3%, stabs – 14%, segmented neutrophils – 62%, lymphocytes – 19%, monocytes – 2%). Erythrocyte sedimentation rate (ESR) – 38 mm/h. Bilirubin – 28 micro-mole/l; total protein – 68 g/l, albumins – 38%; globulins – 62% ((α1 - 47,2 %; α2 - 15 %; β - 15,7 %; γ - 22,1 %). Fibrinogen – 1g/l; C-reactive protein +++. Titer of antistreptolysin – 326 units, antistreptohyaluroni - dase – 875 units. Urea is in norm.

What symptoms of the patient do not belong to clinical picture of rheumatism? What diagnosis can be presumed?6. 7-year-old patient. Suddenly edemas on extremities and on the face

appear, which periodically reduce and then enlarge. After a month from the onset of the disease, shortness of breath, weakness appear. With a diagnosis of chronic glomerulonephritis the patient was placed in a hospital. During examination enlarged liver was detected. Blood: Hb – 100 g/l, globular value – 1,05; leukocytes – 9,1∙ 109 (stabs - 2 %, segmented neutrophils – 90%, lymphocytes – 8%), total protein – 28,0 g/l, albumins – 12 (43%), α1-2 – globulins – 6,7 (24%), β-globulins – 5,0 (18%), γ-globulins – 4,3 (15%). Urine is unchanged. Numerous

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analyses of total proteins gave the same results. The carrying out of complex treatment eliminated all the symptoms.What treatment cured the patient? What diagnosis was made:

a) kwashiorkor; b) idiopathic hypoproteinemia?8. 3-year-old patient. Infancy was normal. Weight 5100g, height 60 cm.

At the age of 5,5 months after introduction of additional feeding muscular hypotonia, swallowing disorder developed. At the age of 1 convulsive attacks appeared. The data of electroencephalogram indicated diffuse lesion of brain, typical of children with development delay. At the examination of amino acids spectrum the increase in level of histidine in blood (150 mg/l) and its daily excretion with urine (510 mg) were detected. During chromatography of sweat and urine a specific test was detected – absence of urocanic acid. Hystidinase activity in the corneal layer of skin was not detected. When a corresponding diet was prescribed, positive dynamics in psychomotor development was observed.

What was the diagnosis? What treatment was carried out?9. A 65-year-old man came to the doctor with complaints of back pain,

loss of weight. During the last months the patient had acute respiratory diseases (ARD) several times. As time went by shortness of breath during physical activity developed. At the examination anemia was detected. In blood serum: Hb= 80 g/l; ESR100 mm/h; albumins – 30 g/l; total protein – 95 g/l; paraproteins in the area of -globulins, urea – 15,0 mmol/l; creatinine – 215 mmol/l; Na – 130 mmol/l; Ca – 2,8 mmol/l. During the X-ray examination detected lytic perforation damages in vertebras, pelvic bones and ribs.

During electrophoresis of blood serum the following electrophoregram was received:

Albumins 1 2 -globulins

Start Comment on the received data of laboratory examinations. Interpret the

results of the blood protein electrophoresis. What diagnosis can be presumed? What additional laboratory examinations can be carried out to make the diagnosis more exact?

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10. During electrophoresis of blood serum the following electrophoregram was received:

Albumins 1 2 -globulins

Start

Comment on the received results of laboratory examinations. Interpret the results of the blood protein electrophoresis.

11. During electrophoresis of blood serum the following electrophoregram was received:

Albumins 1 2 -globulins

StartComment on the received results of laboratory examinations. Interpret

the results of the blood protein electrophoresis.12. At the examination of a patient, the liver was enlarged by 10 cm,

decreased sulemic test, total blood protein – 90 g/l. Electrophoresis of blood serum detected the following:

Albumins 1 2 -globulins

Start

Comment on the received results of laboratory examinations. Interpret the results of the blood protein electrophoresis. What diagnosis can be presumed? What additional laboratory examinations can be carried out to make the diagnosis more exact?

13. A 65-year-old man was admitted to hospital with chest pain after the intensive physical activity. Features of infarction are not seen in ECG. Dynamics of CK was examined within 72 hours. As a result of carried out laboratory examinations was determined: general activity of CK – 300 units/l, 72 hours later – 40 units/l; CK-MB-fraction – at the beginning – 5 units, 72 hours later no activity was detected. Interpret the received results. What diagnosis can be presumed: 1) myocardial infarction;

150

2) excessive physical activity; 3) pulmonary infarction; 4) stenocardia? What enzymic tests must be made to make the result more clear: 1) AST; 2) aldolase; 3) CE (cholinesterase); 4) alkaline phosphatase; 5) isozymes of LDH?

14. 24 hours passed after the heart operation of a 69-year-old patient when it was detected that ECG and hemodynamic indices showed the possibility of microinfarction. Laboratory examinations were carried out: creatine phosphokinase (CPK) – 3100 units/l (N-55-370); CPK-MB – 70 units/l (N – up to 6% of general CPK); LDH – 500 units/l (N-120-230). Comment on the received results. What diagnosis can be presumed: 1) myocardial infarction; 2) pulmonary infarction; 3) myocardial damage at surgery; 4) stenocardia?

15. A 65-year-old man was admitted to hospital after two days since chest pain appeared. At laboratory examinations was found out the following: CPK – 20000 units / l (N – 55-370); AST – 300 units/l (N – 5-45); LDH – 650 units/l (N – 120-230). Comment on the received results. Can the diagnosis – myocardial infarction be made? What additional examinations should be made to make the diagnosis more clear?

16. A patient M. was admitted to hospital with high-grade jaundice, complaints about nagging in epigastric area and right hypochondrium, itch, quick getting tired, irritability. At the laboratoty examinations the following was detected: hyperbilirubinemia with mostly increased conjugate bilirubin; thymol test in norm, ALT – moderately increased. What diagnosis can be presumed: 1) acute hepatitis; 2) obstructive jaundice; 3) hemolytic jaundice; 4) Criggler-Najjar syndrome? What tests of enzymes must be made to make the diagnosis more clear: 1) CE; 2) alkaline phosphatase; 3) SDH; 4) aldolase; 5) LDH?

17. A patient N. was admitted to hospital with complaints about retrosternal pain, sudden weakness, hyperhidrosis, sense of fear, vertigo. At the examination of enzymes the following was detected: activity of AST, LDH – inconsiderably increased. What diagnosis can be presumed: 1) myocardial infarction; 2) stroke; 3) pulmonary infarction; 4) stenocardia? What enzymic tests must be made to make the diagnosis more clear: 1) creatine kinase; 2) aldolase; 3) cholinesterase; 4) alkaline phosphatase; 5) isozymes of LDH; 6) isozymes of CK?

18. A patient I. was admitted to hospital in poor condition with jaundice, weakness, unconscious. At laboratory examinations the following was detected: high-grade bilirubinaemia with mostly increased conjugate

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bilirubin, activity of ALT – within the bounds of norm, CE – considerably decreased. What diagnosis can be presumed: 1) cirrhosis; 2) acute parenchymatous hepatitis; 3) obstructive jaundice? What examinations are necessary to make the diagnosis more clear: 1) AST; 2) SDH; 3) thymol test; 4) isozymes of LDH?

19. A patient B. was operated on for cholelithiasis in a clinic. As anaesthetic myorelaxants were used. In the course of operation the patient had cardiac arrest.What diagnosis can be presumed: 1) overdose of narcotics; 2) congenital deficiency of CE; 3) cardiac insufficiency; 4) allergic reaction? What enzymic tests must be made to define the cause of a sudden complication: 1) CE; 2) alkaline phosphatase; 3) AlAT; 4) CK; 5) isozymes of LDH?

20. In what type of biological material is enzymic examination the most efficient in case of diseases of: 1) liver; 2) cardiovascular system; 3) lungs; 4) kidneys; 5) digestive system; 6) blood; 7) malignant tumors; 8) nervous system; 9) support apparatus; 10) feminine and masculine genital organs; 11) eyes); 12) buccal cavity; 13) congenital enzymopathy:

1. Serum. 2. Lavage liquid (bronchoalveolar lavage). 3. Urine. 4. Ce-rebrospinal fluid. 5. Serous cavity fluid. 6. Synovial fluid. 7. Saliva. 8. Lacrimal fluid. 9. The contents of the stomach. 10. Duodenal contents. 11. Stool. 12. Blood corpuscles. 13. Punctates of tissues. 14. Semen (sperm), prostatic juice. 15. Discharge of feminine genitals. 16. Amniotic fluid.

21. Match the most informative combination of enzymes for examination of the patients with the diseases of: a) liver; b) blood; c) heart; d) kidneys; e) pancreas; f) support apparatus; g) psychic sphere; h) malignant tumors:

1. Amylase. 2. Uropepsinogen. 3. Lipase. 4. Acid phosphatase. 5. ALT. 6. AST. 7. Sorbitoldehydrogenase. 8. Alkaline phosphatase. 9. Glucose 6-phosphate dehydrogenase. 10. Cholinesterase. 11. Lactate dehydrogenase. 12. Isozymes of lactate dehydrogenase. 13. Tripsin. 14. Catalase. 15. Crea-tine kinase. 16. Fructose 1,6-diphosphate aldolase. 17. Fructose monopho-sphate aldolase. 18. Ceruloplasmin. 19. Carbonic anhydrase. 20. Mono-amine oxidase. 21. Acetylcholinesterase. 22. Hexokinase. 23. Arfinase. 24. Adenosine deaminase. 25. Transamidinase. 26. Urokinase. 27. Leucine aminopeptidase. 28. Isozymes of malate dehydrogenase. 29. Isozymes of alkaline phosphatase. 30. Isozymes of amylase.

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22. A woman P. is hospitalized in a poor condition. Consciousness is obscured, adynamia. Skin is dry, eye are deepened. Face cyanosis. Tachycardia. Smell of acetone from the mouth. Tests results: glucose in blood is 20.1 mM/l, in urine is 3.5 %. What diagnosis can be suggested? What additional tests are recommended?

23. While examining of a patient B. it was found out that glucose amount in urine is 0.9 %. Anamnesis is without peculiarities. The results of clinical tests are without pathology. Glycosuria of alimentary and nervous character is denied. Glucose amount in blood is 4.2 mM/l. What diagnosis can be suggested? What is the further tactics of laboratory examination?

24. The blood and urine tests of a patient with insulin-dependent diabetes gave the following results: blood glucose in two hours after breakfast is 18 mM/l, urine glucose is 2 %, glycated hemoglobin is 6.5%. Analyze the results of laboratory tests.

25. The blood and urine tests of a patient with insulin-dependent diabetes gave the following results: blood glucose in two hours after breakfast is 8 mM/l, urine glucose is 0.5 %, glycated hemoglobin is 10.0 %. Analyze the results of laboratory tests.

26. A patient B. with symptoms of exhaustion is hospitalized in poor condition: consciousness is obscured, cold extremities, tachycardia, vomiting, arterial pressure is 90/60, pulse is 110 per minute. Breathing is deep, loud, smell of acetone from the mouth. Laboratory rests of blood: glucose is 38 mM/l, creatinine is 145 micromol/l, urea is 20 mM/l, Na is 130 mM/l, K is 6.0 mM/l, bicarbonate is 5 mM/l, pH is 7.05. Assess the given results. What diagnosis can be suggested? What additional tests are recommended?

27. A young man is hospitalized with pains in abdomen, vomiting, nausea, strong thirsty, pain in chest in the heart region. Breathing is fast. Pulse is 130 per minute, blood pressure is 140/70. In the base of the right lung there is slight crepitation, in epigastric area there is insignificant ache after touching. What diagnosis can be suggested: a) myocardial infarction ; b) diabetes complicated by ketoacidosis; c) infection in gastrointestinal tract? What tests should be made in order to define the diagnosis and its details?

28. Interpret the results of blood and urine tests of a patient with diabetes (who is ill for 25 years): blood glucose is 30 mM/l glycated hemoglobin is 15 mM/l, Na is 135 mM/l, clearance of creatinine is 60 ml per minute. In urine: glucose is 2 %, protein is 5.6 g/l, ketone bodies (-).

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29. A young woman fainted and was hospitalized. Her husband told that during a party the woman had drink several glasses of wine and suddenly lost consciousness. Besides for the last half of the year sudden mood changes and often dizziness were typical for her. She used to lose consciousness several times at the end of a working day. In hospital the woman’s blood was tested and the glucose level was 1.6 mM/l. Glucose was injected intravenously but some time later the woman felt dizzy again. What are the causes of such conditions of the patient? What tests should be made for definition of the diagnosis? Interpret the results of the tests.

30. A woman P. is hospitalized in a poor condition. Consciousness is obscured, adynamia. Skin is dry, eye are deepened. Face cyanosis. Tachycardia. Smell of acetone from the mouth. Tests results: glucose in blood is 20.1 mM/l, in urine is 3.5 %. What diagnosis can be suggested? What additional tests are recommended?

31. A man of 40. In anamnesis: patient’s parents suffered cardiovascular diseases. The patient complains about frequent fits of stenocardia. Tests results: blood plasma is transparent; cholesterol amount is 14.4 mM/l, triglyceride (TG) is 1.7 mM/l, cholesterol of high-density lipoproteins is 0.72 mM/l. What tactics should a doctor use? What is the type of hyperlipoproteinaemia?

32. A child of 10 years, suffers periodical pain in abdomen. There is xanthoma on skin. Examination reveal hepatosplenomegalia Blood serum is turbid. Cholesterol amount is 4.3 mM/l, general lipids amount is 18 g/l. What tests should be made and what diagnosis can be supposed?

33. Interpret the results of blood serum tests, define the type of hyperlipoproteinaemia (HLP). Show electrophoretogram of lipoproteins that conforms to the given type of lipoproteinaemia. Blood serum is transparent, X-lipoprotein (CL) amount is 23 mM/l, triglyceride is 1.4 mM/l, low-density lipoprotein amount is 8 g/l, high-density lipoprotein amount is 1.25 g/l, very low-density lipoprotein amount is 2.0 g/l, chylomicrons amount is 0.2 g/l.

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34. Match the results of lipids research in blood serum with types of hyperlipoproteinaemia:

CL, mM/l

TGmM/l

Lipoproteins, g/l Type of HLP

High-density

Low-density

Very low-density

Chylomicrons

Healthy 2.97-8.79

0.59-1.77

1.25-6.5

3-4.5 1.5-2.0 0-0.5

No 1 8.0 5.4 1.3 2.8 4.7 0.15 II aNo 2 13.0 2.5 1.25 9.0 4.0 0.2 II bNo 3 23.0 1.4 1.25 8.0 2.0 0.1 IV

35. Patient B. with insulin-dependent diabetes, 65 years old, complains about pains in his heart, dizziness, there have appeared xanthomas on his skin recently. The results of blood serum test are: glucose is 10 mM/l, CL amount is 8.0 mM/l, TG amount is 5.4 mM/l, very low-density lipoprotein amount is 4.7 g/l, low-density lipoprotein amount is 2.8 g/l, high-density lipoprotein amount is 1.3 g/l, chylomicrons amount is 0.1 g/l. Blood serum is turbid. After settling a cream-like layer is not formed. Define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to this type of lipoproteinaemia.

36. Interpret the results of blood serum tests, define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to the type of lipoproteinaemia. Blood serum: CL is 7.7 mM/l, TG is 5.2 mM/l, low-density lipoprotein amount is 4 g/l, high-density lipoprotein amount is 6.0 g/l, very low-density lipoprotein amount is 1.5 g/l, chylomicrons amount is 2 g/l. Blood serum is turbid and of milky colour. After settling a cream-like layer was formed, underneath the serum is transparent.

37. Interpret the results of blood serum tests, define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to the type of lipoproteinemia. Blood serum: CL is 42.0 mM/l, TG is 25.2 mM/l, low-density lipoprotein amount is 4 g/l, high-density lipoprotein amount is 5.8 g/l, very low-density lipoprotein amount is 3.8 g/l, chylomicrons amount is 1.7 g/l. Blood serum is of milky colour. After settling a cream-like layer was formed, underneath the serum remains turbid.

38. Patient of 40 years suffers from obesity. After interrogation it is found out that he overused alcohol for a long time. The patient complains about permanent pain in epigastric area. Liver is enlarged by 10 cm. After

155

analysis of blood functional samples serum is found to be turbid. What tests of lipid exchange should be made in this case and why? What results can be expected?

39. A man of 40 complains about permanent pain in his chest, especially during physical exercise. The examination shows xanthomas on his hands and legs. In anamnesis: patient’s father and brother suffered from cardiovascular diseases. Liver, kidneys and thyroid gland function without changes. Arterial pressure is 170/110. Results of laboratory tests: blood glucose is 4.7 mM/l, CL is 16.8 mM/l, TG is 2.4 mM/l, low-density lipoprotein amount is 14.0 mM/l, high-density lipoprotein amount is 0.85 mM/l. What breach of lipid exchange can be supposed? What is doctor’s further tactics?

40. Patient of 40 is hospitalized with diagnosis of acute pancreatitis that showed itself after drinking too much alcohol. The Patient is obese and smokes. He has been suffering from uretic arthritis for 10 years. Examination results: arterial pressure is 150/100. Blood test: glucose is 7 mM/l, TG is 11.9 mM/l, CL is 6.8 mM/l, uric acid is 0.31 mM/l, amount of cholesterol in very low-density lipoproteins are increased. What diagnosis can be supposed: a) hyperlipoproteinaemia, b) hyperlipidaemia, c) cholesteraemia. Explain your choice. What additional tests can be made? What should be the further tactics of a doctor?

41. A woman of 50 has extra weight, long standing hypertension and numerous xanthomas. In her family anamnesis shows that there are no patients with heart ischemia. The results of laboratory tests: Xl is 25.6 mM/l, TG is 15 mM/l. After electrophoresis of lipoproteins it is found out: Start

+ - Interpret the results of electrophoresis. What breach of lipid exchange

can be supposed? What is the doctor’s further tactics?

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42. Interpret the results of blood serum tests, define the type of hyperlipoproteinaemia. Show electrophoretogram of lipoproteins that conforms to the type of lipoproteinaemia. Blood serum: is turbid, Xl is 13.0 mM/l, TG is 2.5 mM/l, low-density lipoprotein amount is 9.5 g/l, high-density lipoprotein amount is 1.25 g/l, very low-density lipoprotein amount is 4.0 g/l, chylomicrons amount is 0.25 g/l.

43. A 42-year-old patient, admitted to hospital with complaints of pains in stomach, nausea, cramps. He has been ill for 10 years. During the last month pains in stomach became stronger, vomiting appeared and in the last 24 hours. During the examination – paleness, malnutrition, xerodermia and xerosis of mucuous tunics.

44. What examinations must be performed: a) glucose; b) packed cell volume; c) ABB results; d) plasma osmolarity; e) plasmatic electrolytes; e) enzymes; f) rest nitrogen, urea?

45. Estimate the results of performed examinations: glucose content – 4,2 mmlol/l; packed cell volume – 0,61; plasma osmolarity – 315 mosm/l; K content – 2,3 mmol/l, Na – 160 mmol/l, Cl – 66,5 mmol/l; ABB: pH=7,6; рСО2=600 mm of mercury column(mm mc); BB = 69 mmol/l; SB = 38 mmol/l; BE=16 mmol/l; ALT – 0,65 mmol/l; AST – 0,48 mmol/l; rest nitrogen – 0,73 g/l; urea – 16,6 mmol/l.

46. What disturbance of water-salt metabolism and ABB was detected: a) respiratory acidosis; b) nonrespiratory acidosis; c) respiratory alkalosis; d) nonrespiratory alkalosis; e) hypokalemic and hypochloremic alkalosis; f) hyperosmolar hyperhydration; g) hyperosmolar dehydration; h) hypo-osmolar dehydration?

47. What is the cause of azotemia?48. What diagnosis can be suggested: a) renal insufficiency; b) pancre-

astic diabetes; c) acute cholecystitis; d) pyloric stenosis?49. A patient K., 45 years, admitted to hospital unconscious. Taking into

account the words of relatives, he suffers from pancreatic diabetes. During the last week he complained about weakness, sleepiness, superficial, rapid breathing, temperature 38 °С, AP (atmospheric pressure) 90/50, no smell of acetone.

50. What examinations must be performed in the first place: a) blood glucose; b) glucose and acetone in urine; c) ABB indices; d) hemoglobin; e) packed cell volume; f) enzymes; g) urea, creatinine?

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51. Estimate the received results of examinations: content of blood glucose – 30 mmol/l; glucose in urine – 5%; no acetone in urine; hemoglobin – 160 g/l; packed cell volume – 0,55; amylase of plasma – 24 g/l; AST – 0,55 units/l; creatine kinase – 12 units/l; urea – 7,8 mmol/l; kreatinine – 0,120 mmol/l. ABB: pH=7,30; рС02 =35 mm mc; BB = 40 mmol/l; SB=21 mmol/l; BO=6 mmol/l.

52. What additional examinations must be performed: a) bilirubin; b) cholesterol; c) electrolytes of plasma; d) plasma osmolarity? Estimate the received results: bilirubin – 17 μmole/l; cholesterol – 6 mmol/l; K content – 6,2 mmol/l; Na – 160 mmol/l; osmolarity – 345 mosm/l.

53. What type of coma does the patient have: a) hypoosmolar; b) hyper-osmolar; c) hypoglycemic acitodic; d) hyperosmolar hyperglycemic nonketonemic; e) uremic?

54. A patient B., 55 years, admitted to hospital with diagnosis of acute pancreatitis. In past history of the patient there is duodenal ulcer, pyloric stenosis on which his was operated 9 years before. Laboratory findings: Hb – 135 g/l; packed cell volume – 0,53; whole protein – 82 g/l; glucose – 17 mmol/l; urea – 18 mmol/l; creatinine – 0,60 mmol/l; ionogram: Na – 159 mmol/l; K – 2,6 mmol/l; Cl – 58 mmol/l. ABB indices: pH=7,56; pCO2= 51 mm mc; BB=55 mmol/l; SB=30 mmol/l; BE=18 mmol/l; plasma osmolarity – 330 mmol/l.

1. Estimate the results of the performed examinations.2. Name the diagnosis for disturbance of water-electrolytic metabolism

and ABB.55. A patient I., 39 years, a miner; 16 years of “dusty service”.

Diagnosis: chronic spasmodic bronchitis. Acute condition of emphysema of lungs at the stage of decompensation. Cor pulmonale. Insufficient blood circulation of the stage III. Fibroradial bronchopneumonia. ABB indices: pH=7,180; p CO2= 101 mm mc; SB = 22,0 mmol/l; AB = 34,1 mmol/l; BB = 51,0 mmol/l. What form of ABB disturbance does the patient have?

56. A patient T., 55 years, a baker. “Dusty service” – 18 years. Diagnosis: acute asthmatic bronchitis. Emphysema of lungs. Bron-chiectases the low left part of lungs. ABB Indices: pH = 7,38; p CO2 = 50,1 mm mc; SB = 24,5 mmol/l; AB = 28,6 mmol/l; BB = 60,5 mmol/l; BE = + 0,8 mmol/l. What type of ABB disturbance can be presumed?

158

57. A patient P., 32 years. Admitted to hospital with complaints about acute pains in the area of stomach. Dyspeptic phenomena. The tongue is dry, furred. Liver is not enlarged. Belly is blown off, tense, pains accompany palpation. Operation. Diagnosis – obstruction. Mesenteric venous thrombosis. ABB indices: pH = 7,18; p CO2 = 30 mm mc; BB = 28,4 mmol/l; SB = 11,4 mmol/l; AB = 10,1 mmol/l; BE = -18 mmol/l. What kind of ABB disturbance can be suggested?

58. A patient V., 22 years, admitted to hospital with complaints about fever, headache, t = 40,5 °С. Sore throat. Diagnosis – paratonsillar abscess. ABB indices: pH = 7,32; p CO2 = 24,4 mm mc; BB = 34,0 mmol/l; SB = 14,8 mmol/l; AB = 12,2 mmol/l; BE = -13 mmol/l. What form of ABB disturbance can be suggested?

59. A patient T., 37 years, brought to hospital unconscious, with cranial trauma. Tachypnoe. ABB indices: pH = 7,58; pCO2 = 24 mm mc; BB = 55,5 mmol/l; SB = 27 mmol/l; AB = 22 mmol/l; BE = +4 mmol/l.

1. What type of ABB disturbance can be suggested? 2. What additional examinations must be performed, on what purpose: a) glucose content in blood; b) global blood test; c) whole protein and fractions; d) packed cell volume; e) tests of coagulogram; f) electrolytes; g) enzymes?

60. A patient U., 48 years, brought to hospital from the automobile accident cite with complaints of pains in the area of chest, difficult breathing. On the examination – cyanosis of cutaneous layer covering, mucous tunics, acrocyanosis, rapid breathing, hypopnoe, pains accompany palpation of the right part of the chest. ABB indices: pH = 7,26; p CO2 = 80 mm mc; BB = 55 mmol/l; SB = 27 mmol/l; AB = 35 mmol/l; BE = +3 mmol/l. What type of disturbance of ABB can be suggested?

61. A patient S., 48 years, admitted to hospital in the resuscitation department with the diagnosis of bronchial asthma, asthmatic status. ABB indices: pH = 7,15; p CO2 = 60 mm mc; BB = 37 mmol/l; SB = 18 mmol/l; BO = 8,0 mmol/l; AB = 19,4 mmol/l. What type of ABB disturbance can be suggested?

62. A patient L., 36 years, admitted to hospital after hanging. ABB indices: pH = 7,24; p CO2 = 84 mm mc; BB = 51,5 mmol/l; SB = 27,5 mmol/l; BE = +4,0 mmol/l; AB = 35 mmol/l. What is the type of ABB disturbance?

159

63 A patient O., 54 years, admitted to hospital with the diagnosis of poisoning with acetic acid. ABB indices: pH = 7,01; p CO2 = 26,5 mm mc; BB = 22,4 mmol/l; SB = 8,05 mmol/l; BO = 22 mmol/l. What is the type of ABB disturbance?

64. What type of ABB disturbance and in what form it can be observed in the organisms of patients with such data of Sigurd-Andersen’s monogram:а) рН = 7,29; 6) рН = 7,33; в) рН = 7,29;рСО2 = 54 mm mc; рСО2 = 31,5 mm mc; рСО2 = 24 mm mc;ВВ = 47 mmol/l; ВВ = 46 mmol/l; ВВ = 31 mmol/l;ВЕ = 2,4 mmol/l; ВЕ = - 8 mmol/l; ВЕ = 13,7 mmol/l;SВ = 22 mmol/l; SВ = 18 mmol/l; SВ = 13,7 mmol/l;АВ = 25,2 mmol/l. АВ = 16 mmol/l. АВ = 11,3 mmol/l. г) рН = 7,55; д) рН = 7,63; е) рН = 7,45;РСО2 = 60 mm mc; рСО2 = 17 mm mc.; рС02 = 22,7 mm mc;ВВ = 74 mmol/l; В = 50 mmol/l; ВВ == 54,0 mmol/l;SВ = 43 mmol/l; SВ = 24,3 mmol/l; SВ = 23,0 mmol/l;АВ = 49,4 mmol/l; АВ = 17,6 mmol/l; АВ = 16,8 mmol/l;ВЕ = + 19,2 mmol/l. ВЕ = 0,4 mmol/l. ВЕ = 2,0 mmol/l.

65 Patient of 54 years. Pensioner, was a pilot in the past. Last years worked with ethyl petrol. From this time began to notice pigmentation of hands, scars. Periodically blisters appear on the opened parts of trunk, extremities. Liver is enlarged on 10 cm. Disorders of protein-synthetic function of liver is marked. General protein - 100 g/l, albumins - 40%, globulins - 60%. Iron in plasma of is reduced to 50%. Urine is of rose colour. Coproporphyrines - 222 mcg/g of creatinine. 1 What diagnosis can be assumed? 2 What additional researches are needed to be done? 3 With what diseases is it necessary to differentiate this disease?

66 Patient 40 years. A driver. In anamnesis abused alcohol. Grumbles about dull pains in right hypochondrium. On the surface of skin covers is scratch, pigmentation, appearance of which the patient can not explain. In urine a red pigment appears periodically. Liver is enlarged on 7 cm. 1 What diagnosis can be assumed? 2 What researches are needed to be conducted? What information will confirm the assumed diagnosis?

67 A 31 years illed patient. Two years ago noticed darkening of skin. On forehead, checks gray dark blue spots appeared. Pigmentation spread on the trunk. Laboratory tests (glucose, bilirubin, Nа, K, Ca) are without changes. Liver is enlarged. A general analysis of blood is without deviati-

160

ons from normal. Concentration of coproporphyrines III is increased in two times. 1 What diagnosis can be assumed? 2 What additional researches must be done? What diseases is it necessary to differentiate this illness with?

68 Patient of 51 years old. Complaints about permanent dull pains in epigastrium, weakness, emaciation, bad sleep, pouring out on the surface of skin of person, neck, hands as blisters. In anamnesis- abuse of alcohol. First noticed such pouring out a year ago. Acute during spring and summer. On inspection of the skin of the hands, neck, is old scars, pigmental spots, blisters. Liver is enlarged on 5 cm. Glucose, bilirubin, cholesterol - is normal. General protein - 90 g/l, hypoalbuminaemia (47%), hyper-β- and γ-globulinaemia. Urine is of red color. Sediment is without changes. Coproporphyrines - 717 μg/day. Uroporphrinogen - 80 μg/day. Concentration of urobilin is considerably increase. What diagnosis can be assumed? What laboratory indexes confirmed diagnosis this?

69 Patient of 33 years old, have been ill for 11 years. Periodically visit the doctor with complaints about acute pains in the stomach. Operated three times. Diagnosis ulcer, pancreatitis, cholecysitis. 11 years from the onset of disease after the attacks of pains in the stomach was found out that urine, is of red color. What diagnosis can be assumed? What researches is it necessary to do for confirmation of this diagnosis?

70 Mr. Н. has been ill for 11 years and was hospitalized with diagnosis of hemolytic anaemia. From childhood pallor, rapid fatigue, was marked. Twice parents noticed appearance of icterity of skin covers and scleras. In the analysis of blood: haemoglobin - 63 g/l; red blood cells - 2,3·1012/л; coloured index - 0,8; thrombocytes - 291·109/l; leucocytes - 4,1·109/l. In a formula: е - 1 %; mc - 2%; y - 1 %; r- 2%; s - 29%; lp - 61 %; - 4%. Hypochromia, anisocytosis, normoblasts 2:100, target-like red blood cells happen for 2-3 in the field of sight. Erythrocyte sedimentation rate (ESR) - 30 mm/hour.1 What diagnosis can be assumed: a) illness of Shenleyn-Genokh; b) eryth-

rocyte enzymepathia; c) hemoglobinosis 5; г) target-like hemoglobino-pathy?

2 What additional researches can be conducted in: a) determining of concentration of НbF; b) electrophoresis of haemoglobin; c) conducting of test on sickle of erythrocytes; г) research of marrow?

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71 Patient С. 32 y. During loading of transport fall down. After liberation felt indisposition, pains in right extremity. Did not visit the doctors and went home to sleep. In the morning woke up with feeling of numbness of extremity, sharp pains. Extremity - was sharply swollen, on palpation. Hospitalized into department of artificial bud. A catheter is used to called which urine is of color. In the urine by the method of elctrophoresis myoglobin is determined. Before hospitalization the clinical picture of acute renal failure was marked in the department. 12 ham analysis was done. What diagnosis is your diagnosis?

72. For a man 60 years during providing of biochemical analysis of blood was discovered hyperuricaemia (0,50 mmol/l). What is probability of development of gout for him. What recommendations of correction of level of uric acid can be offered to the patient?

73. Patient A was hospitalized in a hospital with the attack of kidney colic. During the last years he used an alcohol almost round-the-clock. The analysis of blood found out hyperuricaemia (0,80 mmol/l). Explain the mechanism of origin of hyperuricaemia and kidney colic. Is it possible to diagnose gout? What additional laboratory tests must be provided for clarification of diagnosis?

74. Patient Н. 45 years. During 3 years suffers from difficulty in breathing, scramble-like head pains with vomit and acute pallor of cutaneous covering which are accompanied by palpitation, shortness of breath, high blood pressure. After an attack blood pressure was normalized.

Loss of body wt is 8 kg Results of analyses: AST - 15МО/l; ALT - 20МО/l; cholesterol - 6,2 mmol/l; glucose - 7,5 mmоl/l.

What researches are needed for diagnosing; what diagnosis can be assumed: a) total protein and protein fractions; b) vanillmandelic and homovanillic acids; c) catecholamines; г) glucocorticoids?

75. Patient P. 40 years. Complications on weakness, cramps of higher and lower extremities, high bloody pressure. Results of analyses: concentration of glucose - 4,5 mmol/l; cholesterol - 6 mmol/l; calcium - 2 mmol/l; phosphorus - 1,2 mmol/l; potassium - 2,9 mmol/l; sodium - 180 mmol/l.

What researches are needed for diagnosing, what diagnosis can be assumed: a) alkaline phosphatase; b) thyroxine, triiodthyronin; c) aldoste-ron; d) 17-ketosteroids; e) bilirubin?

162

76. Fill in a table: To “pathology of hormones metabolism”, which contains such columns.Name of

pathologyReason of develop-ment

Clinical symp-toms

Change of laboratory indexes

Diagnos-tical tests

Results of tests Additional researches

Norm Patho-logy

Bring in such pathological conditions into a table: hypopituitarism, acromegaly, giantism, diabetes insipid, Cushing’s disease, Cushing’s syndrome, Addison’s disease, pheochromocytoma.

77. Sick С. 60 years. Complains on pain in bones, muscular weakness, diarrhea, nausea, vomitting, and pains in a stomach. In research, founded stone in kidneys. Results of analyses: concentration of glucose - 4,5 mmol/l; bilirubin - 15 μmol/l; urea - 5 mmol/l; calcium - 3,6 mmol/l; sodium - 140 mmol/l. What researches are needed for determining of diagnosis what diagnosis can be assumed: a) amino-transferases; b) con-centration of phosphate in blood and urine; c) cate-cholamines; г) parathy-rine?

78. Sick M. 25 years. She was often ill quinsies. During a year there is palpitation, strong fatigueability, and shortness of breath, tremor of fingers of hands. Loss of wt 6 kg. Complain about feeling of «internal anxiety», bad sleep, sweatiny. Results of analyses: concentration of glucose - 6,5 mmol/l; cholesterol - 3,11 mmol/l; total protein - 62 g/l; albumens - 51,5 %, α1-globulines - 5,1 %; α2 - 8%; β - 10%; γ- 25%. What is necessary to carry out for clarification of diagnosis what diagnosis is it possible to assume: a) parathyrine; b) aldosteron; c) proteininherited iodine; г) thyroxine, triodthyronine?

79 Patient M. was hospitalized with the expressed jaundice, by complaints about sense of weight in a epigastric area and right hypochondria, itch, fatigue ability, crabbiness. At a laboratory inspection it was determined: hyperbilirubinemia with the overwhelming increase of conjugated bilirubin, thymol test in a norm, ALT is moderately increased.

What diagnosis can be assumed: 1) acute hepatitis; 2) mechanical jaundice; 3) hemolythic jaundice; 4) Crigler-Najjar syndrom? What enzymes tests must be executed for clarification of diagnosis: 1) Cholin-esterase ; 2) alkaline phosphatase; 3) SDH; 4) aldolase; 5) LDH?

163

80 Sick I. was hospitalized in a grave condition with the phenomena of jaundice, weakness, blurr consciousness. At a laboratory inspection was discovered: bilirubinemia is expressed with the overwhelming increase of conjugated bilirubin, activity of ALT within the limits of norm, Cholinesterase is considerably reduced.

What diagnosis can be assumed: 1) cirrhosis of liver; 2) acute yellow atrophy of liver; 3) mechanical jaundice? What researches are needed for clarification of diagnosis: 1) AST; 2) Sorbitoldehydrogenase; 3) thymol test; 4) isoenzymes of LDH?

81. Sick B. was operated in a clinic concerning cholelithiasis. As nesthetic myorelaxants were used. During an operation the stop of cardiac activity happened at sick. What diagnosis it is possible to assume: 1) overdosing of narcotic facilities; 2) born deficit of Cholinesterase activity; 3) cardiac deficiency; 4) allergic reaction? What enzymic tests must be provided for determining of reason of sudden complication: 1) Cholinesterase; 2) alkaline phosphatase; 3) ALT; 4) creatine kinase; 5) isoenzymes of LDH?

82. Patient Z. 48 years. Complaint about the promoted fatigue ability, bad appetite, soon the protracted nausea appeared and once or twice there was vomiting a meal. To the end of the first week a weakness increased sharply. It is marked at a clinical review: a liver is near the edge of costal arc. Analyses from the beginning of disease:

Laboratory index Norm Through3 weeks

Through4 weeks

Bilirubin, μmol/l To 20,52 20,52 8,55Conjugated bilirubin μmol/l To 5,13 10,26 5,13Thymol test, odes. Sulemic test, ml of sulemic reagent Urobilinoids Bile pigments

0—41,6—2,2

Norm -

4,201,60

Norm -

4,402,0

Norm -

164

1) What pathology can be assumed? 2) What additional laboratory researches would help in determining of diagnosis?83. Patient A. 56 years complained about a general weakness, nausea,

inexpressive pains in the stomach of aching character, belch with «rotten eggs». An appetite is bad. In three days urine become dark and an jaundice appeared. Was hospitalized on a 4th day from the beginning of disease. At an inspection the increase of liver the edge of which came forward on 3 - 4 sm. from under a costal arch was marked.Results of laboratory researches:

Laboratory index Norm Icteric periodon a 3th day on a 10th

dayon a 17th

day

1 2 3 4 5

Total bilirubin, μmol/lCholesterol, mmole/lALT, mmol/(s•l )AST, mmol/(s•l)AP, mmol/(s•l)

To 20,523—6,2428—19028—125278-830

107,737,8 8164—

194,949,1522231051653,2

259,9213,6762961481701,4

Index of Protrombin, %Haemoglobin, g/lSedimentation test, mm/hUrobilinoidsBilious pigmentsStercobilin of faeces

70—110120-1401—10Norm—+

9512330 +++++ + -

—13830+++++-

6214230—++++—

1) About what disorder of metabolism of bilious pigments is it possible to discuss? 2) What additional laboratory researches is it expedient to conduct?

84. Gather additionally the most important connection of enzymes for the inspection of patients with the diseases of liver: 1 Amylase. 2 Uropep-sinogen. 3 Lipase. 4 Acid phosphatase. 5 ALT. 6 AST. 7 Sorbitol dehydro-genase. 8 Alkaline phosphatase. 9 Glucose-6-phosphate dehydrogenase. 10 Cholinesterase. 11 Lactatt dehydrogenase. 12 Isoenzymes of lactate dehydrogenase 13 Trypsin. 14 Catalase. 15 Creatinekinase. 16 Fructose-

165

1,6-diphosphataldolase. 17 Fructosmonophosphatealdolase. 18 Cerulo-plasmine. 19 Carboanhydrase. 20 Monoaminooxidase. 21 Acetylcholineste-

rase. 22 Hexokinase. 23 Arginase. 24 Adenosindesaminase. 25 Trans-amidinase. 26 Urokinase. 27 Leucinaminopeptidase. 28 Isoenzymes of ma-latdehydrogenase. 29 Isoenzymes of alkaline phosphatase. 30 Isoenzymes of amylase.

85. Gather additionally of the most rational connections of enzymic tests at the liver diseases for the decision of such clinical tasks: a) early diagnosis; b) differential diagnosis; c) estimations of degree of damage of parenchyma; d) estimations of degree of cholestasis; e) prognosis; f) estimations of transition of acute hepatitis into chronic: 1 ALT. 2 AST. 3 Malatdehydrogenase. 4 Lactate dehydrogenase. 5 Aldolase. 6 Phospho-fructaldolase. 7 Alkaline phosphatase. 8 Sorbitol dehydrogenase. 9 Iso-citrate dehydrogenase. 10 Glutamate dehydrogenase. 11 Ornitincarba-moiltransferase. 12 Cholinetherase. 13 Adenosindeaminase. 14 Isoenzymes of lactate dehydrogenase. 15 Isoenzymes of malate dehydrogenase. 16 Iso-enzymes of alkaline phophatase. 17 γ-GTM. 18 5-nucleotidase.

86. Sick 12 years. Seven years ago suffered from a acute nephrite. Next 5 years the condition remained satisfactory. Analyses of urine and blood are without rejections. At an inspection for a removal from a clinical account was found out violation of secretory function of kidneys. The level of cholesterol rose to 7,3 mmole/l, urea - 6 mmole/l.

Is it possible to take off this child from an account? What diagnosis can be assumed? What researches of blood it is needed to be provided: 1) fibri-nogen; 2) a general protein with protein fractions; 3) TTG; 4) coagulogram; 5) creatinine , indican; 6) urinary acid; 7) calcium; 8) Reberg’s test; 9) con-centration of protein in day's amount of urine?

87. Sick K., 38 years, hospitalized with the expressed edemas of lower extremities, increased АP, decreased diuresis. During hospitalization, condition of middle permanent, pallor and puffiness of face, edemas in combs, shins, feet. Diuresis - 600 ml. Analysis of urine: turbid, a color is yellow, density - 1020, protein - 5 g/l, leucocytes – 10-12 in the field of sight. Analysis of blood: haemoglobin - 100 g/l, red blood cells - 3,1·1012/l, leucocytes - 16·109/l, SR- 46 mm/h. General protein - 55 g/l, albumen - 40 % (22 g/l), kreatinine - 0,18 mmol/l, urea - 24,5 mmol/l.1 What diagnosis can be assumed: a) cardiovascular insufficiency; b) pneu-

monia; c) sepsis; d) renal failure, sharp nephrite?

166

2 What additional researches need to be provided: a) indexes of pH; b) electrolytes in plasma; c) clearence of kreatinine; d) osmolarity of plasma; e) activity of enzymes: ALT, AST, creatinkinase; f) cholesterol; g) packed cell volume?

88. Estimate the results of researches: indexes of: рН = 7,36; рСО2 = 35,2 of m.c.; ВВ=40 mmol/l; SВ=20 mmol/l; ВО=12 mmol/l; concentration of K is 5,9 mmol/l, Na - 130 mmol/l; osmolarity - 280 mosm/l; packed cell volume - 0,38; ALT- 0,85 units/l, AST- 0,6 mmol/l, creatinkinase - 10 units/l; clearence of creatinine (glomerular filtration rate) - 67 ml/min.1 What violation of water exchange and what type of edema take place at

patient: a) dehydration; b) hyperhydration; c) membranogen; г) lym-phogen; д) hypodynamic; е) hypoproteinic?

2 Explain the origin of edemata.89. Gather additionally the most informing connection of enzymes for

the inspection of patients with the diseases of a)kidneys; b) pancreas; c) locomotor apparatus; d) psychical sphere; e) at malignant tumours:1 Amylase. 2 Uropepsinogen. 3 Lipase. 4 Acid phosphatase. 5 ALT. 6 AST. 7 Sorbitoldehydrogenase. 8 Alkaline phosphatase . 9 Glucose-6-phosphatedehydrogenase. 10 Cholinesterase. 11 Lactatdehydrogenase. 12 Isoenzymes of lactatdehydrogenase. 13 Trypsin. 14 Katalase. 15 Krea-tinkinase. 16 Fructose-1,6-diphosphatealdolase. 17 Fructosemonophosphat-ealdolase. 18 Ceruloplasmine. 19 Carboanhydrase. 20 Monoaminoxidase. 21 Acetylcholinesterase. 22 Hexokinase. 23 Arginase. 24 Adenosindes-aminase. 25 Transamidinase. 26 Urokinase. 27 Leucininaminopeptidase. 28 Isoenzymes of malatdehydrogenase. 29 Isoenzymes of alkaline phophatase. 30 Isoenzymes of amylase.

90. Patient 30 years. Three weeks ago was ill on a quinsy. Complains pain in head, weakness, pains in joints, increase of temperature to 39,5°С. Joints at palpation are sickly. Peripheral lymphonodes are a bit megascopic. A liver comes forward from under a costal arc on 3 cm, spleen - on 2 cm. Haemoglobin is 60 gms/l, leucocytes - 3,2 • 109 (eosinophiles - 3%, p - 14%, s - 62%, lymphocytes - 19 %, monocytes - 2 %), ESR - 38 mm/hr. Bilirubin - 28 μmolle/l; total protein is 68 grammes/l, albumen - 38%; globulins -62% (α1 - 47,2 %; α2 - 15 %; β - 15,7 %; γ - 22,1 %). Fibrinogen is a 1 gramme/l; С-reactive protein +++. Volume of antitrypsinolysin - 326 units, antistreptogialuronidaze - 875 units. An urea is normal.

167

What symptoms does the patient have with rheumatitis? What diagnosis can be assumed?

91. Patient I. was hospitalized with complaints on pain in sternum area, sudden weakness, sweat, sense of fear, dizziness. It was discovered at examination of enzymes: activity of AST, LDH - insignificantly enhanced. What diagnosis can be assumed: 1) heart attack; 2) stroke; 3) infarction in lungs; 4) stenocardia? What enzymic tests must be executed for determina-tion of diagnosis: 1) creatine kinase; 2) aldolase; 3) cholin-esterase; 4) alka-line phosphatase; 5) isoenzymes of LDH; 6) isoenzymes of CK?

92. Patient is 63 years old. Hospitalized with complaints on pain in the counter-clockwise half of thorax, shortness of breath at a state of rest. In a clinic on next day after hospitalization: lost consciousness suddenly. AP (arteriotony) is 80/50 mm of hg. A pulse is threadlike, tones of heart are deaf. On ECG there are no changes. Results of analyses: CK – 12 μmol/(min•l) (norm 0-6); AST – 60 μmol/(min•l) (norm 2-20); LDH - 15 μmol/(hr•ml) (norm 0,8-4); leucocytes of blood -12500. What diagnosis can be assumed? What is the tactic the doctor should use n the case?

93. Patient 53 years old is delivered in a hospital by ambulance with a diagnosis: acute heart attack of myocardium. Complaints: pains in the area of heart in a state of rest, acute weakness squeezing. Suffers from hypertensive illness during 10 years. Last two days had pains behind sternum, head pains, weakness. On ECG there is an ischemia at an area in front of lateral and back walls. Results of analysis: concentration of glucose in blood - 8,5 mmol/l; AST - 25 units/(min•l) (norm 2-20); leucocytes-8500; hemogram is without changes; ESR - 12 mm/hr.

What additional examinations must be conducted and what diagnosis can be assumed?

LiteratureI – p. 1-350.

168

APPENDIX AТhe most effective combination of tests in diagnostics of diseases (on D. I. Komarov and L.P.Aksyonenko).

Pathology Test Appointment1 2 3

169

Adrenogenitalic syndrome(inborn):

defect 21- hydroxylase (+ NaCI)

defect 21- hydroxylase (- NaCI)

Defect 11-β- hydroxylase

Defect 3-β-oxysteroid-degydrogenic

Adrenogenitalic syndrome (tumor epinephros)

Аcromegaly

Аgammaglobulinaemia

Albuminuria ortostasisАldosteronism(simple)

Cortisol in bloodadrenocorticotrophic hormonein bloodАndrogens in blood—»— in urine17-Ketosteroids in urinePregnantriol in urine17-Oxycorticosteroids in urine17-Oxycorticosteroids in urine+Na in bloodК+ in bloodNa+/К+ in bloodAdrenogens in blood—»— in urine17-Ketosteroids in urine Pregnantriol in urine17-Oxycorticosteroid in urine17-Ketosteroids in urinePregnantriol in urine17-Oxycorticosteroids in urineDehydroepiandrosteron in bloodNa in bloodК+ in blood17-Ketosteroids in urinePregnantriol in urineDehydroepiandrosteron in urineDexametasone testTest with adrenocorticotrophic hormoneSomatotropin in bloodHydrocsoprolin in bloodІmmunoglobulins in bloodγ- globulins in bloodProtein in urine (ortostasis)Aldosterone in urineК+ in bloodК+ in urineNa in bloodрН bloodHydrocarbonates in bloodрН of urine

D

R RRR!RD

DR!<27RRRRR!RDD!RDRRNR(-)(-)

RDDD(+)!R or ND RRRRR

1 2 3

170

Aldosteronism

Alcaptonuria

Cholangitis

Cholecystitis

Icterus nonhemolytic (syndrome Krigler – Nayar)

Cushing’s syndrome

Hypercorticism secondary (Cushing’s disease)

Dermatomiositis

Diabetes insipidus (primary)

Diabetes insipidus secondary (renali)

Оsmolality of urineRenin in bloodAldosteron in bloodRenin in bloodHomogentisic acid in urineTest with pherychlorid Benedict’s test in urineTest with glycocholic acid in urineBilirubin in bloodАminotransferases in bloodAlkalaine phosphatase in bloodHepatic test in bloodBilirubin in bloodBilirubin in urineUrobilinogen in urineBilirubin in blood (indirect)Bilirubin in bileHepatic test in bloodHydrocortisone and corticosterone(frequent) in blood17-Ketosteroids in urineК+ in bloodрН bloodChloride in bloodDexametasone test (8 mg/day)adrenocorticotrophic hormonein bloodSame data, as under primary HypercorticismDifferences: adrenocorticotrophic hormone in bloodDexametasone test (8 мг/добу)Creatinkinase in bloodAldolase in bloodАminotransferases in bloodLactate dehydrogenase in bloodDaily diuresisRelative density of urineОsmolality of urineGlucose in urineVasopressin testDaily diuresisОsmolality of urineRelative density of urine

DDRRR(+)(+)(-)RRRNRRRRD!N|R

RDRD(-)D

R(+)RRRRRDD(-)(+)RDD

1 2 3

171

Diabetes mellitus

Diabetes coma (ketoacidosis)

Diabetes coma (hyperosmolaris)

Jaundice nongemolytic (Dabin – Gons syndrome)

Galactosemia

Vasopressin testNicotinic testNa in bloodChloride in bloodRenin in bloodGlucose in bloodGlucose in urineІnsulin in bloodАntagonists of insulin (somatotropin, adrenocorticotrophic hormone, hydrocortisone, аdrenaline, glucagon) individual for different forms symptomatic diabetes glycosylated НЬGlucose in bloodGlucose in urineрН of bloodрСОг in bloodexcess based in bloodHydrocarbonat in bloodAceton in bloodKetone bodes in bloodОsmolarity of urineК+ in bloodNa in bloodChloride in bloodNa, K, Cl in urineUrea in bloodCholesterol in bloodОsmolarity of bloodGlucose in bloodAceton in bloodрН bloodexcess bases in bloodBilirubin in blood (conjugated, unconjugated)Bilirubin and urobilinogen in urineBile pigments in fecesHepatic test in bloodGalactose in bloodТyrosine , methionine in bloodGlucose in bloodTest on reduce substance in urineGlucose test in urine

(-)(-)RRRR(+)D or N

RRR(+)DDDD(+)RRN or RDDRRRR!R!(-)DDRD(+)N or ІRRD(+)(-) –

1 2 3

172

Cancer of biliary tract

Gout

Glomerulonephritis acute

Glomerulonephritis chronic

Haemochromatosis (syderophilia)Hemophilia А

Hemophilia В

Аutoimmunity thyroiditis(Hashimoto)

Chronic aggressive hepatitis

Phosphatae in bloodBilirubin in blood (conjusated, unconjusated)Protein in urineBilirubin in blood and urineBile pigments in fecesCholesterol in bloodAlkalaine phosphatase in bloodProthrombine time in bloodUric acid in bloodUria in bloodCreatinine in bloodUric acid in urineThe same under nonpurine dietProtein in urineVolume of urineК in bloodCreatinine in bloodGlomeruli filtration rateγ- і α2-globuline in bloodProtein in urineОsmolality of urineUria, creatinine in bloodClirence of inulineNonorganic phosphate in bloodFe in bloodIron-binding capacity of serum Time of blood clottingTime hemorrhageTromboplastine timeProtrombine timeActivity of VIII factorTime of recalcification Factor IXOther — like gemophilia АTiter antibodes on thireoglobulinAntibodes to microsomic fraction of thyroid glandIodine-binding protein Resorption radioactivity iodine by thyroid glandReumatoid factorAntibody to mitochondrions membrane

DR(+)R(-)RRDRNNRNRDRRDRRDRDRRDRNRNDRD

R

(+)N оr RDR(+)(+)

1 2 3

173

Chronic persist hepatitis

Virus hepatitis

Infarct miocard

Prerenalis nitrogenaemia

Hyperlipidemia:тype І

Australian antibody LgG, γ-globulins in bloodАмmonia in bloodАlbumin in bloodγ-globulins in bloodАLT in bloodGlutamate dehydrogenase in blood Tymol testBilirubin in bloodAlkalaine phosphatase in bloodCholesterol in bloodІgМ, ІgА in bloodLactate dehydrogenase in bloodАLT in bloodАST in bloodCoefficient АLT/АSТSorbitoldehydrogenase in bloodBilirubin in blood (conjusated, unconjusated)Urobilinogen and bilirubin in bloodTymol testElectrophoregram: albumin, α2- і β-globulinsγ- globulins (late)Creatinekinase in blood (CK)Isoenzimes МВ (CK) in bloodLactate dehydrogenase in blood (LDH)Isoenzimes LDH in bloodАST in bloodβ-hydroxybutyrate dehydrogenase in bloodМioglobin in bloodС-reactive protein in bloodUrea in bloodProportion: Urea/Creatinine in bloodUric acid in bloodAlbumin in bloodCa in bloodАST in bloodLactatedehydrogenase in bloodElectrophoresis of lipoproteins:chilomicronsβ-LPpre-β-LP

(+)RRDRRR(+)RRRRRRRRRR(+)(+)!DRRRRRRR

RRRR!>10RDDR

R!NN or D

1 2 3

174

Type ІIа

Type ІІB

Type ІІІ

Type IV

α-LPCholesterol in bloodТAG in bloodPostheparine lipolitic activity Tolerance to fatPlasma color milk, with cream layerunder staingβ-LP pre-β-LPα-LPCholesterol in bloodТriglycerides in bloodPostheparine lipolitic activity Tolerance to glucoseTolerance to fatTransparent plasmaβ-LPpre-β-LPα-LPCholesterol in bloodТriglycerides in bloodTransparent оr turbidity plasmaβ-LPpre-β-LPα-LPCholesterol in bloodТriglycerides in bloodPostheparine lipolitic activity Tolerance to glucose—«— to fatPlasma evenly turbid or 175myla, at standing possible weak cream layerβ-LPpre-β-LPCholesterol in bloodТriglycerides in bloodPostheparine lipolitic activity Tolerance to glucose—«— to fatPlasma transparent or evenly turbidwithout change under standing

DN оr RR!RD

R!NNR!NNNNR!RNR!R

R (fatline)NNRRNІІI

NRN оr RRNІІ

1 2 3

175

type V

Hyperparathyroidism primary

Hyperparathyroidismsecondary (renal)

Hyperthyroidism

Hypertonic disease

Pernicious hypertonic

Chilomicronspre-β-LPβ-LPα-LPCholesterol in bloodТriglycerides in bloodPostheparine lipolitic activity Tolerance to glucose—«— to fatPlasma color milk, with creamlayer under staingCa2 + in bloodNonorganic 176mylase176e in bloodAlkalaine phosphatase in bloodрН of bloodexcess baces in bloodHydroxyproline in urineCa2+ in urineClirence of phosphateParathyroid hormone in bloodParathyroid hormone in bloodCa2+ in urineCa2+ in bloodNonorganic phosphate in bloodNonorganic phosphate in urineТriiodothyroinine and thyroxine in bloodThyroxine linking ability of bloodResorption of radioactivity iodine of thyroid glandIntrodaction of triiodothyroinine test (85 % eases)Cholesterol in bloodCreatinin in urineHydroxyprolin in urineAlkalaine phosphatase in bloodCatecholamines in urine (onset period, primary period)Dophamine-β-hydrolase in bloodRenin in bloodАldosterone in blood and urineК+ in bloodNa in bloodрН of blood

RRDDN оr RRD оr NІІ

RDRDDRRRRRRD оr NRDRDR

(-)

DRRR

RRN оr ІRN оr DN оr DN оr D

1 2 3

176

Renovascular hypertonic

Hypoaldosteroidism ofinborn

Hypoparathyreoidism

Hypophosphotasia

Hypoprotrombinaemia

Hypothyroidism

Cancer syndrome

Crioglobulinaemia

К+ in urineRenin in bloodRenin in bloodАldosterone in urineАldosterone in bloodАldosterone in urineNa in bloodК+ in bloodCa2+ in blood and urineInorganic phosphate in bloodAlkalaine phosphatase in bloodUria in bloodAlkalaine phosphatase in bloodCa2+ in bloodInorganic phosphate in bloodCa2+ in urineTime clotting of bloodPartial tromboplastine timeTime recalcificationTime tromboplastine formationProtrombineТriiodothyroinine and thyroxine in bloodThyrocsinelinking ability in bloodRelated iodine with proteine in blood Iodine, what extraction by buthanoliCholesterol in bloodβ-LP in bloodAlkalaine phosphatase in bloodResorption radioactivity iodine by thyroid glandCreatinin in urineCa2+ in urineTest with TTG not influence on resorption radioactivity iodine thyroid gland and onlevel proteinbinding iodine with primary hypothyreosis; inhancement — with secondaryhypothyreosis5-Oxyindolilacetic acid in urine5-hydroxythiramin in bloodGlucose in bloodHistamine in blood and urineReserpin test: increase of 5-Oxyindolacetic acidPrecipitation of globulins under refrigeration

RRRRDDDRDR

RDN оr RNRRRRND!DRDDRRR

D оr NDD

RRDR(+)

1 2 3

177

Deficiency of proteins (kvashiorkor)

Acute yellow atrophy of liver (hepatic coma)

Primary cencer of liver

Metasthasis of cencer in the liver

Cirrhosis of liver (portal)

Cirrhosis of liver (postnecrotic)

of serum or plasmaAlbumin in bloodγ-globulins in bloodNa and K in bloodGlucose in bloodEnzymes of duodenal containsAmino acids in urineCa2+ in bloodInorganic phosphate in bloodТransferrin in blood Fatty acids in bloodHydroxyproline in urineАlbumin in bloodγ- globulins in bloodBilirubin in bloodHepatic enzymes in bloodАмmonia in blood and urineProtein in urineCrystals of thyrosine and leucine in urine АмinoaciduriaCholesterol in bloodCa, K, Cl in bloodа-fetoprotein in bloodAlkalaine phosphatase in bloodАLT in bloodGlutamatdehydrogenase in bloodAlkalaine phosphatase in bloodLactate dehydrogenase in bloodАlbumin in bloodγ- globulins in bloodAlkalaine phosphatase in bloodLeucinaminopeptidase in bloodFibrinigen in bloodTime of protrombine time in bloodBilirubin in bloodАмmonia in blood and urineТymole testAustralian antibody Same indexes like under portal liver cirrhosis +urobilinogen in urine Coproporphirine in urine

(+)DRDDDRDRDRRDRRR оr DR(+)(+)RDD(+)!RRRRRDRRRDDRR(+)(-)

R(+)

2 3

178

Primarybiliaric liver cirrhosis

Мacroglobulinaemia(Valdenstrem’s disease)

Chronic deficiency of adrenal glands

(Addison’s disease)

Hepatic lenticular degeneration (Konovalov-Wilson’s disease)

Мucoviscodosis

Progressing muscular dystrophy

Myocarditis chronicglomerulonephritis with nephrotic syndrome

Repiat indexis under portal liver cirrhosis+ IgM in blood Antibody against of membrane mitochondrionTotal lipids in bloodCholesterol in bloodBlood viscosityβ2А-globulins in bloodCholesterol in bloodAlbumine in bloodIg G in blood17-Оxycorticosteroids and 17-ketosteroids in urineNa in bloodК+ in bloodNа+/ К+-cofficient in bloodCa2+ in bloodGlycocorticoidsCl in bloodAdrenocorticotrophic hormone testрН, hydrocarbonats in bloodCu in bloodRemoving Cu with urineCerruloplasmine in bloodAmino acid in urine —«— in blood Uric acid in bloodNa and Cl in sweat

Viscosity of secretum of еxcretory glandsNeutral fat in the fecesActivity of enzymes in duodenal contentsHydrocarbonats in duodenal contentsCreatine kinase, lactatedehydrogenase, aminitranspherases in bloodAmino acids in urineCreatine in urineК+ in bloodCreatine kinase, АSТ, LDH in bloodProtein in urineAlbumine in bloodIg G in blood

R

(+)RRR(+)DDDD

DD<30RDD(+) оr (-)DDRDRND>80ммol/LR(+)

D

DRRRDRDR

1 2 3

179

Renal failure

Acute pancreatitis

Chronic return pancreatitis

Pancreas gland cancer

Phaeochromocytoma

Cholesterol in bloodClirence of inulineUrea , creatinine in bloodрН, ВЕ, рСО2 in bloodInorganic phosphate in bloodOsmolarits of urineCa2+ in urineProteins in urineClirence of inulineTotal proteineNa, Ca, К+ in bloodLipase and α-amylase in blood and urine start 3 - 6 hours; мax. 20-30 hours; (lipase little earlierthenmylase)Trypsine in blood and urine (in urine on 3—5 hours later than in plasma)Glucose in blood ( in 20 % of cases) Gluose in urineTolerance to glucoseUrea , creatinine in bloodNa Ca К+ in bloodProteins in urineBilirubin in bloodLipase and 180mylase in blood and urineGlucose in bloodBilirubin in bloodNeutral fat and muscular filament in the fecesTolerance to glucose (in 50 % of cases)In duodenal contents: secretion of hydrocarbonats, enzymesLipase, amylase and trypsine in blood and urineGlucose in urineGlucose in bloodNeutral fat in the fecesBilirubin in bloodТiter of antitrombine in bloodDuodenal contents: activity of enzymes, volume of the secretSecretin test: volume of the secretin, concentration of hydrocarbonats, mylase in duodenal secretАdrenaline, noradrenoline, metanephrine, normetanephrine, valinilalmond acid in urineGlucose in bloodRenine in blood

RDRDRDR(+)DDR

R!

RR(+)ІRD(+)RRRR(+)І

DD(+)R(+)RR

D

D

R!RR

1 2 3

180

Phenylketonuria

Plasmacytoma (мyeloma)

Porphyria:

Acute intermittenChronic late (skin)

Mixed

еrythropoietic uroporphiria (Gunter’s disease)

Pseudohypopara-thyreoidism

Neumonia

Chronic pyelonephritis

Glucose in bloodNoneteriphicated fatty acids in bloodPhenylpyruvate , phenyllactate, phenylacetate in urinePhenylalanine in blood,cerebrospinal liquid, urineInorganic phosphate, excess of bases in bloodProteine in urineγ-globulins (оr-β-globulins)М-gradientBens-Jonson’s protein in bloodCa in bloodInorganic phosphate in bloodVeltman’s testPorphobilinogen and δ-Aminolaevulinic acidin urineRemoving piroles with the fecesUroporphirin and coproporphirin in urineUroporphirin and ethersoluble porphirins bodes in urinePorphobilinogen and δ-Aminolaevulinic acidin urinePorphirin in fecesCoproporphirin and protoporphirin in feces(in the remission)Coproporphirin and protoporphirin in fecesUroporphirin and coproporphirin in urineUroporphirin І in urineCoproporphirin in urineCoproporphirin in fecesCa2+ in bloodInorganic phosphate in bloodAlkalaine phosphatase in bloodEllsvort — Govard’s testParathyr in bloodIsoenzyme LDGз in bloodС-reactive protein in bloodSiales acid in bloodОsmolarit urineRemoving of phenol red, inuline clirenceАlbumin in bloodGlobuline in blood

(+)R

(+)RDRR(+)(+)RRІІ

RD

R

RNN

RRR!RRDRN(-)RR(+)RDDDR

1 2 3

181

Riscets (insufficiency ofvit. D)

Hypervitaminosis D

Acute rheumatitis

Saltlosing nephritis

Hypophysis insufficiency

Bones cancer

Sprue

Thyrosynosis

Ca2+ in bloodInorganic phosphate in bloodAlkalaine phosphatase in bloodCa2+ in bloodInorganic phosphate in bloodAlkalaine phosphatase in bloodα2-globulins in bloodС- reactive protein in bloodGlycoproteins, phibrinogen in bloodHistaminaseКallikreinsМucolitic enzymes (gialuronidase,- N-hexoseaminidasis, (β-glucuronidase)Na, Cl in bloodUrea, creatinine in bloodSomatotrophic hormone in bloodNa in bloodUrea in bloodGlucose in bloodTest with insulinGonadotrophic hormone in urine17-Ketosteroids in urineOther symptoms of reduction function of adrenal suprarenalis,thyroid and sexual glandsCa2+ in bloodInorganic phosphate in bloodAlkalain phosphatase in bloodAcid phosphatase in bloodCa2+ in bloodNeutral fat in fecesProtein in bloodCholesterol in bloodK+ in bloodFe in bloodFolic acid in blood and urineHistidin load test;removing phormiminoglutamine acidAmino acids in urine (especially thyrosine and metionine)Thyrosine and metionine in bloodCrystals of thyrosin in urinePara-hydroxyphenilpyruvate and para-hydroxyphenillactate in urineInorganic phosphate in blood

D оr NDRRRRR(+)RRR

RDRDDN оr DN or DІDD

N or RN or RN or REN or RRDDDDDR

RR(+)

RR

1 2 3

182

Obstructive joundice

Zolinger —Ellison syndrome

Hypernephroma

Renine secreting cancer ofkidneys

Exudative enteropathy

Acute leukemia

Еclampsia

Inorganic phosphate in bloodInorganic phosphate in urineGlucose in bloodG-Амinolevulinic acid in urineConjugated bilirubin in blood and urineSorbitoldehydrogenaseInorganic phosphate in bloodLeucinaminopeptidise in bloodGama glutamiltranspeptidaise in blood5-nucleotidaseBile pigments in fecesUrobilinogen in urineCholesterol in bloodGeneral lipids in bloodCeruloplasmine in bloodGlucose in bloodHCl in gastric contentsGastrin in bloodрН, НСО- з , excess of bases , К+ in bloodCa in bloodNa in bloodNa in urineLactate dehydrogenase in urineAlkalaine phosphatase in bloodТimol testProtrombine timeАlbumin in bloodα2 –globulines in bloodRenin in bloodАldosterone in urineК+ in bloodАlbumin in bloodγ- globulins in bloodLipids, cholesterol, Fe, Ca in bloodNeutral fat in the fecesCholinesterase in bloodLactatdehydrogenase in bloodAST in blooduric acid in bloodАlbumin in bloodBilirubin in bloodUria in bloodGlucose in bloodLactatdehydrogenase in blood

DRDRR!DR!RRR(-)(-)R!R!RDR!D

DRDRRRIRDRR!RDDDDRRRRRDRRD оr NR

183

1 2 3

Systemic lupuserythematosus (LE)

Bilirubin in bloodАlbumin in bloodUric acid in bloodUria in bloodGlucose in bloodInorganic phosphate in bloodFibrinogen in bloodАlbumin in bloodγ- globulins in bloodImmunity complexes in blood

RDRRRRRDRR

Note. D-decrease; R-raise; 1— indexes or reaction are changed; N—rate; (+)—positive result of the test ; (—) —negative result of the test ; ! — particularly significant change

Таb А.2- Periods most information of enzymes indexes under myocardium infarction ( F. 1. Komarov)

Enzymes tests Begin increasing of activitys, hour

Маx activity,hour

Restorationback to normal

activity

Degree of the maximum increase to activitys

Creatinkinase 2—4 12—24 1—4-days 50

АST 6—12 24—36 3—5-days 15—30

LDH 12-24 36—72 10—12-days 20

LDH1-2 612 24—36 2—3-weeks 20

Таb А.3 - criteria for activitys of the rheumatic process ( F. 1. Komarov)

Тest Degree of activity

III II І

ESRС-reactive protein α1-globulins

before 30 мм/hour3+, 4+ and more 23

—25%

before 20—30 мм/hour

from + before 3+21—23%

mildly increased+(-)

mildly increased or rate

Seromucoid 0,8—2,0 од. 0,3 —0,8 од. rate or mildly increased

Serological titres(ASL-0, ASK, ASG)

above rates in 2—3 times

above rates in 1,5—2 times

within upper borer of the rate or mildly

increased

Note. АSL-0 — antistreptolysing titre ; АSK — аntistreptokinaise titre; АSG -antistreptogialuroinide titre.

184

Таb А.4 -activity of enzymes in blood under disease of the heart muscle ( F. 1. Komarov)

Enzyme Cipher DiseaseMyocardium

infarctionStenocardia Miokarditis

АST 2.6.1.1 powerfully increased

nearly always

increased

АLT 2.6.1.2 sparingly increased

N same

Fructosediphosphat-aldolase

4.1.2.13 same nearly always N

sparingly increased

Lactate dehydrogenase 1.1.1.27 increased same N or sparingly increased

Creatinkinase 2.7.3.2 powerfully increased

N increased

Маlatedehydrogenase 1.1.1.37 increased same NCholinesterasa 3.1.1.8 reduction —«— sameHexsophosphateiso-merase

5.3.1.9 increased —«— —«—

Таb. А.5 - Differential diagnostic of myocardium infarction and pulmonary embolism ( F. 1. Komarov)

Disease CPC Lag Isoenzymes LDG AST ALT

myocardium infarction + + + ++ LDH1-2 ++ + (+ +)

pulmonary embolism + LDH3-5 + ++

185

Таb А.6 - Enzymes tests in differential diagnosis of pains in the thorax and abdominal cavity ( F. 1. Komarov)

Disease Type of the change Ratio of enzymes activity

Myocardium infarction average increasing CK>АST>АLT ≥Амilase» Glu-DH

Right ventricular failure very significant increasing АST≈АLT ≈ Glu-DH >CK≥ Amilase

pulmonary embolism not increasing or average АLT>АST> Glu-DH≥ CC ≥ Аmilase

Pleurisy in most casesnot increasing

______

Thrombosis of the abdominal vessels

average or small increasing AST ≈ALT>Аmilase > Glu-DH» CK

Acute pancraetitis same Аmilase » АLT>АST≈Glu-DH > CK

Biliary colic average increasing АLT>АST> Glu-DH>Аmilase ≥ CK

Kidney colic in most cases notincreasing

______

Shock significant or stronglyincreasing

CK≥АST>АLT> Glu-DH > Аmilase

Таb. А.7 - laboratory tests in differential diagnostics ascites ( F. 1. Komarov)

Disease BST ТT BIL АLB GLB AP

Cardic insufficiencyCarcinomatosis

Тuberculosis

Liver cirrhosis

(++)

(+) or N

same(+ + +)

N

same

(+)(+)

(+)

N

same(+)

N оr (—)

same

-«-(-)

N

same

(+.)(-)

(+)

(+ + +)

(++)(-)

Note. BST — bromsulpholeinic test ; ТT—тymol test; BIL — bilirubin; АLB—аlbumin; GLB—globulins; AP—alkaline phosphatasae; (+) — increase; (—) — discrease.

Таb. А.8 - Differential diagnostic of liver diseases ( F. 1. Komarov)

186

Bioche-mical test

Acute hepatitis

Chronic persistence hepatitis, liver cir-rhosis in phase intensifications

Chronic active hepatitis

Liver cir-rhosis (portal, postnecrotic)

Fats degeneration of liver

Benign hyperbilirubinaemia

Billiary heaptitis

1 2 3 4 5 6 7 8Total

bilirubin +++ + to++ ++ N(+) N(-) - ++

Conjuga-ted

+++ + to++ ++ same samе ++Dabin-Johnson’s

++

Unconju-gated

N(+) N(+) N(+) -»- -»- +Julber’s ++

AST ++ + to++ + to++ -«.- -»- N + to++ALT +++ ++ ++ -«- -»- same + to++

LDH + + + to++ —»— —»— —»— +LDH5 ++ ++. ++ + —»— —»— +

Glutamatdehydro-genasae

+ + + N(+) —»— -»- + to+++

SDH +++ ++ ++ same -»- —»— +

Cholines-terase

- - - - (-) (-)

Alcaline phospha-

tase

N(+)

Undercholestasis (+)

Undercholestasis (+)

++

Total protein - - - - - -

Аlbumin - - - - - -

γ-globuins

N(-) ++ +++ ++ N(-) +

Sedimental test

++++++ +

same++

Prothrom-bin

++ - - N(-) N(-)

Cholesterol

+ + N (-) N (-) N (-) N (-) N (+)

Bilious pigments in urine

++ + + + + + +

Note. + increasing; ++ observably increasing; +++ sharp increasing; (+)can be increased; - is reduced; -- observable reduction; (—)can be reduced

187

Таb. А.9 - To differential diagnostics of the jaundicesBiochemical test Jaundice

Haemolytic Liver Liver withcholestasis

mechanical (obstructive)

Bilirubin conjugatedNonconjugatedАSTАLTLDHLDH5

GlutamatdehydrogenasaeAlcaline phosphataseАlbuminSorbitoldehydrogenaseSedimental testCholesterolProthrombinUrobilin bodys (urine)Bile pigments (urine)

----++NNN

absentNNNNNNN++-

+++

++++++++

++++++-

++++——++

+++

++++++++

+++++

+++-

++++

+ (-)—

+ (-)+

+ to+ +++++

N+++NNN+N-+

Note. + increasing ; ++ observably increasing; +++ sharp increasing ; — decreased; (—)can be reduced; N — rate.Note. Haemolytic and mechanical jaundice under postliverobturation can accompany the defects of the liver.In this case, can fall out positive liver tests that it is necessary to take into account

Таb. А.10 - Differential diagnosis of comatose states under diabetes mellitusType of coma

Skin Diuresis Hlycemia ABB Contents Contents of ketone bodys

Na K N In blood In urine

1 2 3 4 5 6 7 8 9 10

Hyperglu-cosemia (ce-toacidosis)

Dry Polyuria High Metabolic acidosis

N It is re-duced

N Sharply increa-

sed

High

Hyperosmolaris (non-aciddotic)

Dry Polyuria Veryhigh

N High It is re-duced

High N Abcent

188

1 2 3 4 5 6 7 8 9 10

Lactacide-mia (lactate

acidosis)

Dry Anuria,.oliguria

Sparingly increased or

normal

Metabolic acidisis

N + High High N Abcent

Hypoglu-cosemia

Moist N Low N N N N N Abcent

Таb. А.11 Factors of laboratory test ,which is used for differential diagnosis of the disease ,accompanied by pains in the abdominal cavity

Disease AST ALT Glu-DH Alkaline phosphatas

e

α-amilase Other laboratory

indexesAcute

pancreatitis

Kidneys colicLiver colic

Enterospasms

Heart attack of the myocardium

(atypical)

Acute hepatitis

(+), +

N+, ++

N

++

+++

(+), +

N+, ++

N

N, (+): +

+++

N, (+), +

N++

N

N

++

(+)

N++

N

N

(+), +

+++

NN, (+), +

N

N

N

α-amylase in urine: ++, +++

HematuriaHyperbilirubine

-mea_____

CK, LDH, hydroxybutiratdehydrogenasa

(++, +++)

Hyperbilirubine-mia

Note: N—normal, (+)—weak increase, +— increase, ++-—high increase, +++-—very high increase. < Glutamatdehydrogenase — mitoxondrial enzyme of hepatocytes. Аt heart attack, myocardium exists in in the same way typical change on ECG does.

Таb А.17 - Rates of laboratory indexes (V. G Kamishnikov)

189

Factors rate in unit,which it is necessary to change

factor recalculation

rate in unit СІ

Total buffer baces (ВB)excess (or deficit) buffer baces Pressure of carbon-dioxide (рСО2) in blood:- аrterial- venousePressure of oxygen (р02) in blood:- аrterial- venousTotal carbonic acid (ТСО2)Fatty acidstotal:- free (on an empty stomach)- free (after receiving the food)Corticosteroids(11-ОKS)Corticosteroids(17-ОKS)Creatinine:- in women- in menCreatinine clearance-test:- in men- in womenCreatinkinase (CK)Lactate dehydrogenaseTotal lipidsα2-MacroglobulinLithium

—

+2,3—(—2,3) мекв/л

35—45 mm. cs. c.46—57,9 mm. cs. c.

90—95 mm. cs. c.35—45 mm. cs. c.

—

9,0—15,0 mcv/L0,64—0,88 mcv/L

0,78—1,18 mcv/L

13—23μg/100ml

5—20,0 μg/100ml

0,5—1,10 μg/100ml0,5—1,30 μg/100ml

97—13 ml/(min1,73)88—128ml/(min1,73)

0—20 МО/L

0,8—4,0 μmol/(min-ml)350,0—800,0 mg/100ml

—0,35—1,4 mg/100ml

—

1,000

1,1330,133

0,1330,133

—

1,0001,000

—

0,027

0,028

8888

0,00963—

0,060

1,000,010

—1,44

40,0—60,0 mmol/L

4-2,3—(—2,3) mmol/L

4,65—5,98 cPa6.1—7,7 cPa

12,0—12,6 cPa4,6—6,0 cPa

23—33 mmol/L

9,0—15,0 mmol/L0,64—0,88 mmol/L

0,78—1,18 mmol/L

0,358—0,635 μmol/L

0,14—0,56 μmol/L

44,0—97,0 μmol/L44,0—115,0 μmol/L

0,93—1,32 ml/(sm2)0,85—1,23 ml/(sm2)

0—1,2 μmol/(min-ml)

0,8—4,0 μmol/(min-ml)3,5—8,0 g/L

1,83—4,47 μmol/L0,49—2,02 mmol/L

190

Factors rate in unit,which it is necessary to change

factor recalculation

rate in unit СІ

191

Мg (on raction with titanium yellow)Мg (reactive with mangan)Мg of brain liquidCopperLactate in blood:- venous- аrterialUric acid:- in men- in womenUreaNa of plasmaNa of erythrocytesNoradrenaline 11-ОKS in plasms of blood (on fluorescens in H2SO4 alcohol so-lutions)17-ОKS in plasms of bloodPyruvic acidPlasminogen PrealbuminProthrombine

SeromucoidSerotonin:- in plasma- in bloodSialic acidSorbitol-degydroge-nasaeТymol testTranspherrin

TrilglyceridesTripsinFibrinogen

1,7—2,6 mg/100ml

1,5—2,0 mecv/l2.5—3,5 mg/100ml70,0—140,0 μg/100ml

5,0—15,0 mg/100ml3,0—7,0 mg/100ml4,0—8,5 mg/100ml2,8—7,5 mg/100ml15—50 mg/100ml300—360 mg/100ml130—157 mecv/l13,5—22,0 mecv/l0,65—0,90 μg/l

13,0—23,0 μg/100ml

5.0—20,0 μg/100ml0,4—1,0 mg/100ml--10,0—15,0 mg/100ml7%22,0—28,0 mg/100ml

4,4±0,9 mcg/100ml9,0—18,0 μcg/100ml62,0—73,0 mg/100ml0,00—0,02 μmol/L (min-l)

0,4 ed. S—Н200.0-320,0 mg/100ml200,0 – 320,0 mg/100ml50,0—150,0 mg/100ml1,0—4,0 nmol/L (min-l)200,0—4.00,0 mg/100ml200,0—400,0 mg/100ml

0,411

0,50,4110,157

0,1110,111

0,0590,0590,1660,4351,0001,0005,911

10,000

0,027114,0--0,1401,0000,010

0,0570,0570,0191,000

1,0000,1790,0100,01160,0000,0100,029

0,7—1,07 mmol/L

0,75—1,00 mmol/L1,03—1,44 mmol/L11,0—22,0 μmol/L

0,56—1,67 mmol/L0,33—0,78 mmol/L

0.24—0,50 mmol/L0,16—0,44 mmol/L2,5—8,3 mmol/L130—157 mmol/L130—157 mmol/L13,5—22,0 mmol/L3,84—5,31 mmol/L

130—230.0 μg/l

0,14—0,55 μmol/L45,6—114,0 μmol/L1,4—2,8 mmol/L2,64—6,50 μmol/L1,4—2,1 μmol/L7%0,22—0,28 g/l

0,25±0,05 μmol/L0,51—1,02 μmol/L2,00—2.36 mmol/L0,00—0,02 mmol/L (min-l)

0-4 ed. S-Н35,80—57,28 mmol/L2,0—3,2 g/l0,55—1,65 mmol/L60,0-240,0 mcmol/L (min-l)2,00—4,00 g/l5,80—11,60 mcmol/L

Factors rate in unit,which it is necessary to change

factor recal-culation

rate in unit СІ

192

Phosphatase acidAlcalineTotal phospholipidsPhosphate:- in lipids- inorganicFructose (blood)Chloride-ion (Cl-) Cholesterol (total):- on Liberman- Burhard- on Zlatcis -ZacCholesterol in а-LP (а-Cholesterol)CholinesteraseCaeruloplasmin

0,05—0,13 μmol/L (min-l)0,50—1,30 μmol/L (min-l)152,5—362,5 mg/100ml

6,10—14,5 mg/100ml2,0—4,0 mg/100ml0,5—5,0 mg/100ml95,0—110,0 mecv/l

116,0—242,0 mg/100ml120,0—250,0 mg/100ml35,0—75,0 mg/100ml

160.0—340,0 μmol/h-L15,0—60,0 mg/100ml

1,0001,0000,013

0,3230,3235,5511,000

0,0260,0260,026

1,00010,000

0.05—0,13 μmol/L (min-l)0,50—1,30 μmol/L (min-l)1,98—4,71 mmol/L

1.97—4,68 mmol/L0,65—1,29 mmol/L2,77—27,75 μmol/L95,0—110,0 mmol/L

3,0—6,2 mmol/L3,1 —6,5 mmol/L0,9—1,9 mmol/L

160,0—340,0 mmol/h-L150,0—600.0 mg/L

Indexes of blood clotting systemFactors rate in unit,which it is

necessary to changefactor re-

calculationrate in unit СІ

Time of the bleeding- on Dyuc- on Aivi

1—4 min1—7 min

--

1—4 min1—7 min

Time of blood coagulation on Li and White- in glass test tube- in silicon test tube

5—6 min14—20 min

--

5—10 min14—20 min

Kaolin-kephalic time 35—45 sec 35—45 secRecalcofication time 60—150seс - 60—150seсАutocoagulogramm on 10 minuts 9—11seс - 9—11seсFibrinogen B ----- - -----Еthanol test Negative - NegativeProtaminesulphate test Negative - NegativeТolerance of plasma to heparin on Sigg’s 6—13 min - 6—13 minFibrinolisis: - spontaneous- euglobines

10—20 %150—260 min

--

10—20 %150—260 min

Factors rate in unit,which it is necessary to change

factor recal-culation

rate in unit СІ

Fibrinase 50—100с ----- 50—100сReaction of the blood clot 60-80 % - 60-80 %Hematocrit: - in men- in women

40-48 %36-42 %

-0,01

0,40—0,48 ml/L0,36—0,42 ml/L

Appendix A continuation Hepatotoxic medical preparations (acc. N.U.Tic)

193

А. preparations, causing cholestasisАsatioprin Мercasolil (metymasol)Аminarson (carbason) Nicotinic acidАminosalicilic acid PenycillinАndrogens Oral contraceptivesBensodiasepin ProgestinsErithromicyn SulphanilamidsЕstrogen s SulphonisІmisin (imipramine) PhenothyasinsCarbamasepin ChlorpropamidMepropan (meprobamat) B. preparations,damaging liver hutchesАsatioprin МethoxyphluranAllopurinoll МethotrecsatАminosalicilic acid Nicotinic acidАmytriptyllin Novocainamide (procaynomid)Аndrogens PapaverinАsparaginase ParamethadionАcetylsalicilic acid ParacetamolButadion (phenilbutason) PenycillinValproic acid Oral contraceptiveVarfavin (seldom) PyrasinamideDantrolen ProbenecydDiphenin Salts of FeЕstrogen s SulphanilamidesЕthanol (in excess) ТethracyclinesЕtionamide Tethuram (dysulphiram)Іbuprophen Тrymethyn (thrymethadion)Іsoniaside PhenasopyridinІnhibitor of MAO PhenobarbitalІndomethacyne Phtorotan (galotan)Carbamasepine Phuradonine (nytrophurantein)Levomycetine (chloramphenicol-seldom) ChinidinMercaptopurin Chlorbutine (chlorambucil)Methyldopha Chlorpramid

Chloprapamide

Literature

194

I. William J Marshall. Clinical Chemistry. – Mosby, 2000. II. С. Ангельськи и соавт. Клиническая биохимия / Пер. с польського. -

Сопот, 1998.III. Зилва Дж. Ф.Клиническая химия в диагностике и лечении / Перевод с

англ. - М.: Медицина, 1988.IV. Гарбарець Б.О., Висоцький І.Ю., Качанова А.А. Практикум з медичної

біохімії. – К., 1998.V. Лабораторные методы исследования в клинике: Справ. / Под ред.

В.В. Меньшикова. – М.: Медицина, 1987.VI. Посібник з клінічної лабораторної діагностики / За ред. В.Г. Денисю-

ка. – К.: Здоров’я, 1992.VII. Клінічна лабораторна діагностика. Практичні заняття з клінічної біоті-

мії / За ред. М.А. Базарнової, З.П. Гетте. – К.: Вища школа, 1994.VIII. Клиническая оценка лабораторных тестов / Под ред. Н.У. Тица. – М.:

Медицина, 1986.IX. Клиническая оценка биохимических показателей при заболеваниях

внутренних органов / Под ред. В.Г. Передерия, Ю.В. Хмелевского. – К.: Здоров’я, 1993.

X. Хмелевский Ю.В., Усатенко С.К. Основные биохимические константы человека в норме и при патологии.– К.: Здоров’я, 1987.

XI. Мусия Я. Основы биохимии патологических процессов.– М.: Медицина, 1985. – Разд. 4, 5.- Ч. ІІ.

XII. Норма в медицинской практике: Справочное пособие. – М: МЕДпресс-информ, 2002.

XIII. Данилова Л.А. Анализы крови и мочи. – М.: Медицина, 2002.XIV. Руководство по клинической лабораторной диагностике / Под ред.

М.А. Базарновой, В.Т. Морозовой. – К.: Вища школа, 1986, 1990.XV. Р. Хомен, Д. Шейх. Очерки по патологической биохимии.– М.:

Медицина, 1981.XVI. Мак-Мюррей У. Обмен веществ у человека.– М.: Мир, 1980.XVII. Основы патохимии / Под ред. А.Ш. Зайчик, Л.П. Чурилов. – Санкт-

Петербург: Элби-СПб, 2000.XVIII.Біологічна хімія: Лабораторний практикум / За ред. Я.І. Гонського. –

Тернопіль: Укрмедкнига, 2001.

Сontents

195

Introduction……………………………………………………........3

List of practical topics………………………………………………5

Lesson 1. Biochemical tests in clinical medicine.Monitoring of medical drugs………………………………………...6

Lesson 2. Normal and pathological indexes of proteins and nonprotein nitrogen metabolism…………………………………….8

Lesson 3. Clinical enzymology. Enzymodiagnostics………………22

Lesson 4. Clinical and laboratory diagnosis of breachesin carbohydrate metabolism...………………………………….…..32

Lesson 5. Laboratory investigations and biochemical diagnosticsof breaches in lipids and lipoproteins metabolism…………………42

Lesson 6. Diagnostic criteria of disturbance of water, sodium, potassium metabolism. Determination of acid-base balance..……..53

Lesson 7. Clinical-laboratory diagnostics disirders of violationsof hemoproteins, porphyrines and iron metabolism. Clinical-laboratory diagnosis of disorders nucleotides metabolism ………..62

Lesson 8. Clinical-laboratory diagnostics of hypothalamus, hypophysis, adrenal and sexual glands disorders…………………..78

Lesson 9. Clinical-laboratory diagnostics of functional activityof thyroid and parathyroid glands. Biochemical investigations of disorders of calcium, phosphates and magnesium metabolism.……87

Lesson 10. A clinical estimation of biochemical indexes is at

196

liver and biliary ways diseases …….………………………………94

Lesson 11. A clinical estimation of biochemical indexes inkidneys diseases …………………………………………………..106

Lesson 12. Disorders of gastrointestinal tract functions, their diagnostics and diet therapy…………………………………119

Lesson 13. Laboratory diagnostics of the inherited metabolic diseases. Features of clinic-laboratory diagnostics of diseases ofextreme age. Biochemical aspects of pregnancy and early child’s age…………………………………..128

Lesson 14. Biochemical indexes at oncologic diseases. Clinical-laboratory diagnostics of the cardio-vascular system, connective tissue, breathing organs diseases ……………………136

Lesson 15. Conclusion session……………………………………147

Appendix A………………………………………………………..169

Literature………………………………………………………….196

197