Case 1:

50-year-old man presented for routine checkup. On further

questioning, a previous history of renal stone has been noted.

Serum
Sodium 140 mmol/l (135-145)
Potassium 3.9 mmol/l (3.5-5.0)
Urea 5.5 mmol/l (3.0-8.0)
Creatinine 90 mol/l (50-120)
Albumin 40 g/l (36-48)
Calcium 2.90 mmol/l (2.20-2.62)
Phosphate 0.72 mmol/l (0.82-1.40)
ALP 155 IU/l (40-100)
GGT 60 U/l (<100)

a. Comment on the calcium status of the patient and list the

biochemical abnormalities.

b. Plasma PTH was assessed and found to be 4.5 pmol/l

(reference: 1.0 5.5). What is your interpretation? What is
the most likely diagnosis?

c. What is the most likely tissue source of the elevated plasma

ALP?

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Case 2:
70-year-old man, chronic smoker, presented with haemoptysis and
weight loss.

Plasma

Sodium 140 mmol/l (135-145)

Potassium 3.9 mmol/l (3.5-5.0)
Urea 5.5 mmol/l (3.0-8.0)
Creatinine 90 mol/l (50-120)
Albumin 30 g/l (36-48)
Calcium 3.10 mmol/l (2.20-2.62)
Phosphate 0.72 mmol/l (0.82-1.40)
ALP 155 U/l (40-100)
GGT 132 U/l (<100)

a. Calculate the albumin-adjusted calcium.

b. Please list the biochemical abnormalities.

c. Plasma PTH was assessed and found to be < 1.0 pmol/l

(reference: 1.0 5.5). What is your interpretation? What is the
most likely diagnosis?

d. What is the most likely tissue source of the elevated plasma

ALP?

2
Case 3:

The following are biochemical results from 2 patients both with

renal impairment.

Plasma Patient 1 Patient 2

Calcium 1.80 3.20 (2.20-2.62 mmol/l)

Albumin 30 30 (36-48 mmol/l)
ALP 160 160 (40-100 U/l)
Urea 18.3 18.3 (4.5-8.0 mmol/l)
Creatinine 450 450 (50-120 mol/l)
Phosphate 2.0 2.0 (0.82-1.40 mmol/l)
PTH 20 20 (1.0-5.5 pmol/l)

a. Please comment on the calcium status of Patient 1.

b. What is the cause of the elevated PTH in Patient 1?

c. Please comment on the calcium status of Patient 2.

d. What is the cause of the elevated PTH in Patient 2?

3
Case 4:

A 50-year-old woman has been diagnosed with a fungal infection

and was given Amphotericin B. After one week, she began to
complain of generalised paraesthesia in her limbs.

Plasma

Sodium 135 mmol/l (135-145)

Potassium 3.1 mmol/l (3.5-5.0)
Urea 4.0 mmol/l (3.0-8.0)
Creatinine 70 mol/l (50-120)
Calcium 1.82 mmol/l (2.20-2.62)
Albumin 40 g/l (36-48)
Phosphate 1.50 mmol/l (0.60-1.40)

Plasma magnesium 0.29 mmol/l (0.71-1.00)

a. Please list the biochemical abnormalities.

b. How does plasma magnesium affect calcium homeostasis?

c. What is the cause of the hypomagnesaemia?

4
Case 5:

A 74-year-old woman was referred to an orthopaedic surgeon for

investigation of severe low-back pain. She was otherwise well. X-
ray of the pelvis showed coarsened trabeculation and some loss of
bone density.

Plasma

Sodium 141 mmol/l (135-145)

Potassium 4.1 mmol/l (3.5-5.0)
Urea 5.3 mmol/l (3.0-8.0)
Creatinine 87 mol/l (50-120)
Calcium 2.05 mmol/l (2.20-2.62)
Albumin 40 g/l (36-48)
ALP 214 U/l (21-90)
Phosphate 0.49 mmol/l (0.85-1.40)

a. Please list the biochemical abnormalities.

b. What is the most likely diagnosis and what additional test would
you request?

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Case 6 [past exam question]:

A 44-year-old male who has been consuming on average 2 glasses

of double-distilled chinese wine per day for the last 20 years
complained of recent onset of paraesthesia of the lips and facial
muscle twitching. He also noticed change in bowel habit for the
last 6 months. He complained of much flatulence, the passing of
one bowel motion per day which was pale in colour, of soft
consistency, foul smelling and difficult to flush. He has also lost 8
kg in weight in the 6 months. On examination, he was of slim built
with no pallor and no jaundice. BP was 110/60 mmHg with a pulse
rate of 80 bpm. Abdomen was non-tender. The liver was nodular
and was palpable 2 cm below the costal margin. There was no
ankle oedema. His medical records revealed 2 previous admissions
for acute pancreatitis. The following biochemical results were
obtained for the present consultation:

Plasma
Reference Intervals:
Sodium 135 mmol/L 134 145
Potassium 4.5 mmol/L 3.5 5.1
Urea 4.4 mmol/L 3.4 8.9
Creatinine 80 mol/L 44 80
Total protein 72 g/L 66 81
Albumin 26 g/L 36 48
Total bilirubin 20 mol/L < 15
ALP 190 U/L 35 100
ALT 60 U/L < 58
Amylase 56 U/L 28 100
Total Calcium 1.52 mmol/L 2.15 2.55
Phosphate 0.66 mmol/L 0.82 1.40

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1. Calculate the plasma albumin-adjusted calcium concentration
for this patient and based on this result determine if the patient
was hyper-, hypo- or nomocalcaemic.

2. What is the likely cause of his plasma calcium and phosphate

results?

3. What test(s) would you request to confirm your suspicion in

question 2 above?

4. What factor(s) may have contributed to the elevated plasma ALP

concentration?

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Case 7:

A 2-month-old infant was brought to a paediatrician due to right

limb twitching. The infant was alert with no dysmorphic feature
and there was no focal neurological signs.

Plasma
Reference Intervals:
Sodium 140 mmol/L 134 145
Potassium 4.0 mmol/L 3.5 5.1
Urea 3.4 mmol/L 3.4 8.9
Creatinine 45 mol/L 44 80
Total protein 72 g/L 66 81
Albumin 43 g/L 36 48
Total bilirubin 8 mol/L < 15
ALP 646 U/L 35 100
ALT 34 U/L < 58
Total Calcium 1.51 mmol/L 2.15 2.55
Phosphate 2.53 mmol/L 0.82 1.40
Magnesium 0.80 mmol/L 0.711.00

Further investigations:
Plasma
Ionised calcium 0.74 mmol/L 1.13 1.32
PTH 13.2 pmol/L 1.6 6.9

a. List the biochemical abnormalities.

b. Interpret the PTH result.