Quiz 3

Ref: Harrison 20th page 2867 – 68
 Sitagliptin is ruled out as DPP – 4 inhibitors are associated with risk of pancreatitis
 Liraglutide is ruled out since it is available in injectable format and patient has refused to take injections
 Pioglitazone has black box warning due to risk of bladder cancer.
 Canogliflozin will be the most suitable for the patient since it will help in reducing the weight of the patient as well.

Ref: CMDT 2019 page 1226
 The patient is already diabetic at the time of conception. Since organogenesis occurs in first trimester, it is imperative to achieve good sugar control in T1. Hence serum fructosamine is recommended, because it accurately describes glycemic control retrospectively for previous 1 – 2 weeks.
 Glycosylated hemoglobin gives information about retrospective control of diabetes mellitus for previous 8 – 12 weeks and is not suitable in the case given in the question.

Ref: CMDT 2019; page 1235
 All GLP – 1 receptor agonists are associated with increased risk of pancreatitis. Exenatide is documented to cause haemorrhaginecrotising pancreatitis.

Ref: CMDT 2019; page 1255
 A patient of type 1 diabetes mellitus is on Continuous subcutaneous insulin infusion. Due to device malfunction tubing malfunction the delivery of insulin was halted.
 Since patients of type 1 diabetes are ketosis prone, she has gone into diabetic ketoacidosis. The low bicarbonate points to acidosis.
 The patient’s elevated blood sugar is drawing water into the intravascular compartment and hence volume expansion explains the sodium deficit.
However there is no need of hypertonic saline as correction of hyperglicemia by insulin shall suffice in managing sodium values.
 Hypertonic saline is only given in acute onset hyponatremia with neurological features.
 If severe hypothosphatemia can develop (< 1mg/dl), phosphate should be replaced at no more than 3 – 4 mmol/h via infusion.
 Potassium replacement should be started in 2nd and 3rd hours as acidosis begins to resolve.

(Ref Harrison 20th p 2729; Harrison 19th edition, page 2319)
 The presence of hypertension and hypokalemia incriminates increased aldosterone values. For evaluation of primary hyper-aldosteronism plasma renin/aldosterone ratio is useful.
 ACTH stimulation test is done for Addison disease that presents with postural hypotension with hypokalemia.
 24 hour urinary catecholarnines is used for diagnosis of pheochromocytoma.
 Octreo-scan is used for locating carcinoid tumour and primitive neuro-ectodermal tumours.

(Ref: Harrison 19th p 2472)
 The distinctive bone manifestation of hyperparathyroidism is osteitis cystica fibrosa, which Histologically, shows and increase in the giant multinucleated osteoclats in scalloped areas on the surface of the bone (Howship's lacunae) and 3 replacement of the normal cellular and marrow elements by fibrous tissue.
 X-ray changes include resorption of the phalangeal tufts and replacement of the usually sharp cortical outline of the bone in the digits by an irregular outline (subperiosteal resorption).

(Ref: Harrison 20th p 2935; Harrison 19th edition Page 2480-82)
• Giucocorticoids are used in management of hypercalcemia due to sarcoidosis, vitamin D intoxication, vitamin A application.
Management of dangerous hypercalcemia
1. Hydration with saline
2. Saline can be administered with furosemide and can be given twice daily to depress the tubular reabsorptive mechanism for calcium (Avoid dehydration or it will worsen hypercalcemia).
3. IV use of pamidronate and zolendronate is approved for the treatment of hypercalcemia; between 30 and 90 mg pamidronate, given as a single IV dose over a few hours, returns serum calcium to normal within 24-48 hours with an effect that lasts for weeks in 80-100% of patients.
4. Calcitonin nasal spray for its rapid onset of action.

(Ref: Harrison 20th p 2955; Harrison 19th p 2501)
Atypical femoral fracture in subtrochanteric femoral region or across femoral shaft are side effects of prolonged bisphosphonate use.
In the question patient is complaining of pain in right hip and thigh. Thus differential diagnosis of the patient can be
1. Fracture of neck of femur or shaft of femur.
2. Chronic pain probably not bony in origin; instead, it is related to abnormal strain on muscles, ligaments, and tendons and to secondary facet-joint arthritis associated with alterations in thoracic and/or abdominal shape.
3. Lumbar spinal canal stenosis resulting in nerve compression
 Fracture neck of femur is the first differential and requires evaluation by
X-RAY.