Thanks to David Williams (Reading) for suggesting this Case.
A 70 year old man, seeing his Family Doctor. Clinical information is
'Diabetic annual review'.
Serum results were
Sodium: 140 mmol/L
Potassium: 5.1 mmol/L
Urea: 8.4 mmol/L (2.8 - 7.0)
Creatinine: 165 umol/L (62 - 133)
Glucose: 11.0 mmol/L (random, 3.5 - 10.0)
Albumin: 39 g/L
Globulins: 35 g/L
Cholesterol: 5.0 mmol/L
Bilirubin: 11 umol/L
Alkaline phosphatase: 267 IU/L (<126)
ALT: 46 IU/L (<56)
Fructosamine: 305 umol/L (non-diabetic, 205-285)
This case attracted 36 participants.
2 would make no comment on these results; [0.4*]
1 queried an old or badly stored sample, and suggested a repeat. [-0.6]
7 participants thought the fructosamine suggested reasonable/ moderate
glycaemic control; [0.8]
4 thought poor/ sub-optimal recent glycaemic control. [0.5]
14 commented on the mild renal impairment, [0.8]
1 suggested the patient was dehydrated, [-1.2]
1 queried the use of diuretics, [-1.0]
1 queried malnutrition. [-1.8]
15 commented on the increased alkaline phosphatase: [1.2]
6 querying bone origin, [0]
5 querying Paget's disease, [0.2*]
2 querying hyperparathyroidism, [-1.1]
1 the fatty liver of DM, [-0.2]
1 a hepatic space-occupying lesion. [-0.6]
12 would suggest urine microalbumin, [0.2]
10 would measure calcium and phosphate, [1.4]
10 would measure gamma-GT, [1.4]
8 would measure alkaline phosphatase isoenzymes, [1.2]
8 would suggest HbA1c, [0.6]
4 would suggest measuring blood pressure, [-1.0]
4 would suggest PSA, [-0.2]
3 would suggest a creatinine clearance, [-0.2]
3 would ask for a fasting glucose sample, [-0.6]
1 each would suggest
LDL-cholesterol, [0.2]
triglyceride, [0.2]
protein electrophoresis, [-0.8]
bicarbonate and chloride. [-1.0]
1 would suggest referral to a Diabetes Physician. [-1.0]
There was disagreement between the assessors on a couple of points,
indicated by asterisked scores. Several assessors were concerned about the
suggestion to monitor blood pressure. My own feeling is that this
suggestion is akin to my clinicians telling me that I should perform
quality control on sodium analyses; and I personally would feel very
aggrieved if any of them did this.
We still don't know quite what is going on with this patient: calcium and
phosphate were normal, gamma GT [283 IU/L] and globulins [41 g/L] were
raised, alkaline phosphatase isoenzymes showed equal amounts of bone and
liver, serum protein electrophoresis showed a generalised increase in
immunoglobulins, and urine electrophoresis showed a slight generalised
proteinuria [0.26 g/L].
Best wishes
Gordon Challand
Li Ping
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