Chart 17 :

A 55-year-old business woman underwent medical screening program provided by the

company as part of annual health checkup including assessment of thyroid function.
Interpret the biochemical investigations.
Result Normal range
Serum TSH 4.5 µIU/mL (0.3 – 5 µIU/mL)
Free T4 1.8 ng /dL (0.8 – 2.7 ng/dL)
Free T3 380 pg /dL (210- 440 pg/dL)

1. What is your diagnosis? Justify.

Euthyroid status. Normal TSH, Normal fT4 and Normal fT3
2. What is the advantage of estimating free T3 and free T4 over Total T3 and T4?
When TBG concentrations get altered, there will be a false alteration of Total T3 and
T4, in spite of the person remaining in a euthyroid status. However, TSH, Free T3 and
Free T4 do not get altered by alterations in TBG
3. What are the differences between T3 and T4?
T3 is the most active form of Thyroid hormone, as T3 binds with the receptor with
higher affinity than T4. T4 concentration is higher than T3 and T4 is more plasma
protein bound. T4 half life (7 days) is longer than T3 (1 day). T4 cannot cross placenta,
T3 can cross placenta
4. What are the other tests which can be used to assess the thyroid?
Plasma TSH test, TRH response test, thyroid antibodies test

Chart 18

A 24-year-old physiotherapist consulted his general practioner because of excessive

sweating and was also concerned that his eyes seemed to have become more prominent
and that he had lost weight recently although his appetite was normal. he also complained
ofpalpitation
On examination, his doctor observed that the pulse rate was 100/min at rest and
also had a slightly enlarged thyroid gland.
 Result Normal range

Serum TSH < 0.1 µIU/mL 0.3 – 5 µIU/ml

Free T4 3.2 ng/dL 0.8 – 2.7 ng/dL

Free T3 880 pg/ dL 210- 440 pg/dL

1. What is your diagnosis? Justify.

Grave’s disease. Hyperthyroidism (clinical features and lab findings – low TSH and
high fT3 and high fT4) with goiter and exophthalmos
2. What is the cause of tachycardia in this condition?

Thyroxine causes upregulation of β adrenergic receptors in all target tissues

(including heart). Β adrenergic receptor stimulation causes tachycardia.

3. What is the explanation for the eye prominence in this condition?

Grave’s disease is an autoimmune disease. LATS Ab (Long Acting Thyroid

Stimulator Antibodies) cross react with the receptors on the preadipocyte fibroblasts
of retroorbital tissues and stimulate the fibroblasts. Activation of fibroblasts releases
cytokines. Cytokines cause edema in the retro-orbital tissues, which causes
exophthalmos.

4. What is the reason behind weight loss in this condition?

Thyroxine is an uncoupler and hence it increases the Basal Metabolic Rate. Hence, in
hyperthyroidism, BMR is increased, fuels do not accumulate in the body causing
weight loss.

Chart 19

A 20-year-old woman presented with weight gain, hair loss, menstrual irregularities. She
had become intolerant to cold weather and developed constipation. Her voice had changed. Her
skin has become dry and yellowish. She also had noticed a fullness in the neck. On
examination, his physician observed a pulse rate of 60/min and his ankle & knee jerks were
sluggish.
 Result Normal range
Serum TSH 25 µIU/mL 0.3 – 5 µIU/mL
Free T4 0.4 ng/dL 0.8 – 2.7 ng/dL
Free T3 180 pg/dL 210- 440 pg/dL
Serum cholesterol 520 mg/dL

1. What is your diagnosis? Justify.

Hypothyroidism.
High TSH and low fT3 and low fT4
Clinically, weight gain, cold intolerance, constipation, Bradycardia,
pseudomyotonic reflexes are all suggestive of hypothyroidism

2. What is the cause of yellowish discoloration of the skin in this condition?

Thyroxine is necessary for the conversion of β carotene to the active form vitamin
A, retinal. Hence, in hypothyroisim, β carotene accumulates in skin causing
yellowish discoloration. This is called as carotenemia.

3. What is the explanation for high cholesterol in this condition?

Thyroxine reduces blood cholesterol, because it causes upregulation of LDL
receptors in all target tissues and it clears of LDL. Hence in hypothyroidism, LDL
accumulates in blood causing hypercholesterolemia.

4. What is the reason behind weight gain in this condition?

Thyroxine is an uncoupler and hence it increases the Basal Metabolic Rate. Hence,
in hypothyroidism, BMR is reduced, fuels accumulate in the body causing weight
gain.

Chart 20

A 45-year-old male presented with an apparent reduction in the urine output. He was
subjected to renal function testing. The values were:
 Blood Urea : 23 mg/dL

Serum Creatinine : 0.7 mg/dL

24 hours urine : 1600 mL

Urinary Creatinine : 80 mg/dL

1. Calculate the Glomerular Filtration Rate

U → 80 mg/dL
V → 1600mL/24hrs
1600/1440 mL/min
1.11 mL/min
P → 0.7 mg/dL
GFR = 80 * 1.11
0.7
=127 mL/min

2. Comment on the GFR.

Normal renal function as the GFR is 127mL/min (Normal is more than 90mL/min)

3. What is the significance of eGFR or estimated GFR?

As GFR changes with age, sex and race, estimated GFR is calculated using a
mathematical formula including serum creatinine, age, sex and race.
Few formulae used are COckraft Gault formula, CKD EPI formula

4. Why is Cystatin C considered a better GFR marker?

It is produced at a constant rate and freely filtered by kidney glomeruli. It is

completely reabsorbed. The blood levels are not depended on age, sex, muscle mass or
inflammatory processes. It is sensitive to changes in the creatinine blind area of GFR (40–70
mL/min/1.73m2).

Chart 21

A young man sustained multiple injuries in a motorcycle accident. He received blood

transfusions and underwent surgery, 24 hrs after admission, he had only passed 500 mL of
urine. He was clinically dehydrated, and his blood pressure was 90/ 50 mmHg.
Investigations:
Serum:
Potassium : 5.6 mmol/L
Urea : 126 mg/dL
Creatinine : 1.5 mg/dL
Urine:
Sodium : 5mmol/L
Urea : 1880 mg/dL

1. What is the probable diagnosis? Justify.

Acute Kidney Injury
Acute based on duration
Kidney Injury because Serum Urea and Creatinine are high (indicating an inability of the
kidney to filter urea and creatinine from serum)
Serum Potassium is high (indicating an inability of the kidney to secrete potassium)
2. What is the significance of urinary Urea and sodium in this case?
If the urinary Urea : Serum Urea > 10 , Urinary sodium < 20 mmol/L and Fractional
Excretion of Sodium <1%, it is prerenal failure.
3. Why do you see elevated Potassium in this patient?
Decreased renal function interferes with kidneys’ ability to maintain fluid and electrolyte
balance. The ability to concentrate urine declines early and is followed by inability to
excrete phosphate, acids and potassium
4. Name a biomarker that could be useful in this patient.
Urinary neutrophil gelatinase associated lipocalin (uNAGL)

Chart 22
A 56-year-old man presented to his family doctor with loss of appetite, weight loss,
generalized weakness and lethargy of six months duration. During this time, he had been
passing more urine than usual, particularly at night. On examination, the patient was
anemic and had BP of 180/110 mmHg. His urine contained protein but no glucose. A
blood sample was taken for analysis.
Serum:
Sodium : 130 mmol/L
Potassium : 5.2 mmol/L
Bicarbonate : 16 mmol/L
Urea : 258 mg/dL
Creatinine : 7.1 mg/dL
 Glucose (random) : 116 mg/dL
Calcium : 7.2 mg/ dL
Phosphate : 8.6 m6 /dL
Albumin : 2.8g/dL
Alkaline phosphatase : 205 U/L
Hb : 9.1 g /dL

1. What is the probable diagnosis? Justify.

Chronic Kidney Disease
Six months duration
High potassium indicates kidney’s inability to secrete potassium
High urea, high creatinine, High phosphate indicate kidney’s inability to filter

2. Why is serum calcium low in this condition?

In chronic kidney disease, kidney is unable to synthesise the active form of vitamin D (1
alpha hydroxylase, which converts 25 hydroxy vitamin D to 1,25 DH vitamin D, is present
in kidney). Low vitamin D is the cause of low calcium.

3. Why is the ALP level high in this condition?

Low calcium causes secondary hyperparathyroidism. Parathormone stimulates
osteoblasts and that causes an elevation of ALP.

4. Why is Hemoglobin low in this condition?

Erythropoietin is produced by kidney and in CKD low erythropoietin production is the
cause of anemia