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Student Discussions: 2017: February 26th to July 20th

For discussion during this semester
1. A patient has diabetes, hypertension and chronic kidney disease. His serum alanine transaminase is noted to be persistently high at 127U/L (about three times the upper limit of normal) for over 3 months. The other parameters of his liver function test are normal. He is negative for Hep B surface antigen and antibodies to Hep C. His total cholesterol and LDL cholesterol are both high at 8mmol/L and 5mmol/L respectively. His triglyceride level is also high at 2.6mmol/L. With this information, suggest possible reasons for his abnormal ALT value.

Response: Possible causes of raised ALT:
1)Non-Alcoholic Fatty Liver Disease
2)Alcoholic liver disease
3)Medication induced
4)Viral hepatitis
5)Autoimmune hepatitis
7)Extrahepatic (thyroid disorder, celiac disease, hemolysis, muscle disorder)

2. A man with chronic kidney disease has mild anemia with a hemoglobin of 10.2mg/dL. His serum iron is 9.9umol/L (normal 10.7 to 32.2) and his total iron binding capacity is 74umol/L (normal 38.5 to 85.9). Is his anemia due to iron deficiency?

Response: Iron deficiency anaemia classically shows low serum iron with high TIBC. In this case, TIBC is still within the normal range. In a man with chronic kidney disease, it is likely that his anaemia is due to anaemia of chronic disease. Management-wise, I would like to start him on haematinics (elemental iron, folic acid and vitamin B12) with Vitamin C supplement to help with absorption of iron. Elemental iron is for replacement of iron store whereas folic acid and vitamin B12 are provided because in the event of increased erythropoiesis following increased iron store, these two may become depleted.
One item in this response needs discussion

3. A woman is being treated for hypothyroidism with Tab Thyroxine 75 ug OD. Her serum T4 is 13.73pmol/L (normal) and her serum TSH is 11.22mIU/L (high). She is clinically euthyroid. Is any dose adjustment of Thyroxine necessary?

From her thyroid function test, her serum T4 is normal while her serum TSH is high. This indicates subclinical hypothyroidism. Although she is asymptomatic and clinically euthyroid, there is a necessity to increase her dose of thyroxine. Dosage should be adjusted to maintain normal TSH levels as the aim of thyroxine in subclinical hypothyroidism is to make the patient clinically and biochemically euthyroid.

4. A 67 year old man developed pulmonary edema in April 2012. He had AF at that time. His echocardiogram showed severe mitral regurgitation and cardiomegaly with dilatation of all four chambers. The anterior mitral valve leaflet was noted to be flail. His coronary angiogram was normal and he underwent mitral valve replacement three days later. What do you think is the cause of his mitral regurgitation?

the cause is most likely due to dilated cardiomyopathy. When the left ventricle dilates, the papillary muscles and the cordae tendinae (supports of mitral valve) stretches which eventually causes mitral valve incompetence, mitral regurgitation. The mitral regurgitation is most likely the cause of the atrial fibrillation in this case. The patient also presented with pulmonary oedema, which shows that he most probably is in heart failure. Other causes may include, infective endocarditis, rheumatic heart disease or a previous MI.

5. Look at this report (question 5). It is a coronary angiogram report and it shows significant 3 - vessel disease. Currently, 2 years after this angiogram was done, the patient reports feeling well with no chest pain on exertion. He remains on medical therapy and did not undergo any revascularisation procedure. How will you explain his lack of cardiac symptoms?

His lack of cardiac symptoms could potentially be the result of his adherence to his medications which comprises of nitrates, antiplatelet, statin, ACE-inhibitor, and trimetazadine. ……. asymptomatic patients may have a normal TIMI Grade 3 flow despite the 3 vessel disease. That being said, the mechanism of why some individuals experience chest pain and some are symptom-free, is not fully understood. There have been proposals such as : 1) Higher pain threshold in ischemic episodes 2) Shorter duration and less severe ischemic episodes 3) Generalized defective perception of painful stimuli 4) Defective anginal warning system 5) Higher beta-endorphin levels 6) Higher production of anti-inflammatory cytokines, which may block pain transmission pathways and increase the threshold for nerve activation

6. The patient shown in this picture (Question 6 had undergone a procedure to insert a therapeutic device in the left infraclavicular region. This therapeutic procedure was done after he suffered loss of consciousness and was noted to have bradycardia. What is the therapeutic device and what do you think was the diagnosis at the time he suffered syncope?

The device inserted is an artificial, permanent pacemaker. Possible diagnoses include: slow AF/ 3rd degree Heartblock/ ischemic heart disease/ sick sinus syndrome.

7. A patient has the following arterial blood gas results: pH (7.28); PaCO2 (42.3mm Hg); PaO2 (84.4mm Hg); HCO3 (20mmol/L); What kind of acid base disorder does this patient have? Also, does this ABG show any evidence of a pulmonary diffusion defect or ventilation-perfusion imbalance?

The result of ABG shows metabolic acidosis in view of an acidotic ph (7.28) and low HCO3 (20mmol/l). In the case of metabolic acidosis, patients are suppose to have respiratory alkalosis (high pH, and low Co2) as a compensatory mechanism. But the Co2 remains at the upper limit of the normal value, which means to say the patient is not breathing well to wash out the carbon dioxide levels in his blood, could be due to a lung pathology or any condition that interferes with the ability of oxygen get to the alveoli or anything that prevents blood flow to the capillaries. The likely cause for his ABG is due to a V/Q mismatch, where there is some areas in the lungs are better perfused by blood and some areas are better ventilated than perfused. Likely cause of v/q mismatch is due to hypoxia.

8. A 55 year old woman had a vasovagal syncope in December 2016. Physical examination and all investigations including ECG were normal at that time. She had an ECHO done in March 2017. It showed dilated right atrium and tricuspid regurgitation. Both ventricles were normal size and LVEF was 55%. Is there a link between the ECHO findings and her syncope?

There is the possibility that the tricuspid regurgitation caused a decreased supply of oxygen rich blood which led to the brain undergoing cerebral hypoxia which caused the syncope. However, this would indicate a severe disease process, and hence biventricular hypertrophy would be expected. In this instance, a transient arrhythmia would be suspected. If there is no evidence of an arrhythmia and no ventricular hypertrophy, this ECHO findings and syncope are most likely unrelated.

9. A patient with DM, HPT and CKD has a hemoglobin of 9.9gm%. Her serum creatinine is 188umol/L and her serum K is 5.5mmol/L. She takes insulin, atorvastatin, aspirin, perindopril and felodipine. How will you decide whether the elevated serum K is significant enough for her to be admitted in the hospital? What changes in her current treatment will you make?

This patient has mild hyperkalemia with raised creatinine. In this case, the most probable cause of hyperkalemia is due to reduced potassium excretion. Common causes would include renal failure and medications that interfere with potassium excretion, namely potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, and non-steroidal anti-inflammatory drugs. She is currently on perindopril and aspirin which can affect potassium excretion. This patient need not be admitted into the hospital and can be treated as outpatient. Her medication should be re-evaluated and changed, and her potassium and creatinine should be monitored for laboratory signs of severe hyperkalemia and acute worsening of renal function, which requires hospitalization.

10. A 50 year old woman underwent surgery for atrial septal defect when she was 30 years old. She was admitted for congestive cardiac failure in January 2017. In March 2017, she is feeling better even though she has breathlessness on walking fast. On examination she has central cyanosis and atrial fibrillation without any evidence of heart failure. Her ECHO showed dilated LA, dilated RA, with a normal LV ejection fraction. Why does she have central cyanosis? Why are her atria dilated?

1) it was a failed correction. 2) she developed pulmonary hypertension with right to left shunting in lungs and masked left ventricular restriction 3) during surgical repair, inferior vena cava return to the left atrium by inclusion of Eustachian valve

11. A 49 year old man has been on antithyroid drugs for past 10 years for toxic nodular goitre. Currently he is on Tab Carbimazole and his serum T4 and TSH are both normal. He is reluctant to stop Carbimazole because of recurrence of hyperthyoidism on every occasion when he stopped it in the past. What is the appropriate advice for him regarding his thyroid disease?

for this patient, I would suggest him to go for radioiodine or surgery. This is because even after being on tablet carbimazole for 10 years, it seems that there is no remission……Thyrotropin-receptor antibodies level should also be checked as those with persistently high level after one or more years of treatment are unlikely to remain euthyroid after carbimazole is stopped.

12. A 33 year old woman has unexplained persistent hypokalemia. She was admitted twice in the past with fatigue and muscle weakness. What will you suspect if her blood pressure was high? What will you suspect if her blood pressure is normal?

High blood pressure and hypokalaemia: Conn’s syndrome (primary aldosteronism), Cushing’s syndrome, Liddle’s syndrome
Normal blood pressure and hypokalaemia: Essential hypertension with diuretic use

13. A 55 year old woman is diagnosed as chronic Hepatitis B carrier. How is this diagnosis made?

HBsAg positive; Anti-HBs negative; HBeAg negative; Anti-HBe positive; Anti-HBc positive; IgM anti-HBc negative; ALT normal

14. A 69 year old man has breathlessness on exertion. There are fine crepitations heard in both lungs on auscultation of the back of the chest. He does not have cardiac failure. His spirometry shows reduced FEV1 and reduced FVC but normal FEV1/FVC ratio. What type of disease can explain his breathlessness?

The reduced FEV1 and FVC indicates restrictive ventilator defect. The reduction of lung volumes can be caused by intrinsic lung diseases (e.g: interstitial lung disease, acute pneumonitis), mechanical compression on the lungs that limits lung expansion (e.g: chest wall/pleural disorder) and neuromuscular disorders which decrease the ability of respiratory muscle to inflate and deflate the lungs. since the reduction of FEV1 and FVC in ILD are in proportion to the decreased lung volume, the FEV1/FVC ratio is normal.

15. A 62 year old woman was diagnosed as bronchial asthma and congestive cardiac failure with atrial fibrillation two years ago. Now, her ECHO shows mitral stenosis, mitral regurgitation. Explain what you think about the diagnosis offered to her two years ago and what kind of heart disease she has.

I think the diagnosis made 2 years ago is unlikely. Symptoms of AF, CCF, bronchial asthma can happen in both MS and MR. Bronchial asthma may be misdiagnosed due to the presence of bronchial obstruction secondary to enlarged LA. Secondly, it is very rarely that bronchial asthma is diagnosed at old age. In short, the presence of both MS and MR suggests that she may have rheumatic heart disease. CCF symptoms are due to enlarged LA pressure and subsequent pulmonary congestion and cor pulmonale.

16. A 69 year old man has breathlessness. His spirometry showed FEV1 to be 0.91 Litres (which is 31% of predicted value 2.95 L) and FVC to be 1.37 Litres (which is 44% of predicted value 3.08 L). What do you think is the cause of his breathlessness?

Both his FEV1 and FVC is decreased and his FEV1/FVC ratio is 0.66 which indicates that he might have an obstructive lung disease such as asthma, COPD or bronchiectasis.

17. A woman with Marfan's syndrome desires pregnancy. She asks about her risk of cardiovascular complications during pregnancy. How will you decide what to tell her?

….perform an echocardiogram. If the aortic root diameter < 45 mm – reassure her that pregnancy is safe, no significant CVS complications. However, frequent follow up maybe needed………..If the aortic root diameter > 45 mm – she has higher risk of a composite adverse outcome in pregnancy such as death, aortic dissection and severe symptomatic aortic regurgitation. Therefore, elective aortic surgery may be needed prior to the pregnancy.

18.A 60 year old woman with IHD and HPT is on these medicines: Perindopril, Amlodipine, Simvastatin, and Aspirin. She developed bilateral pedal edema recently but denies any shortness of breath on exertion or orthopnoea. Clinical examination shows that she is not in heart failure. Suggest a reason for her pedal edema. What medication do you think she may need apart from those that she is currently taking?

One of the possible reason for bilateral oedema may be due to the use of calcium channel blocker, Amlodipine in her case. She should also be started on a beta-blocker (eg bisoprolol) as beta blocker has been shown to reduce mortality associated with heart failure

19. A 56 year old man, a smoker with hypertension, has significant memory loss for past many months. He also experiences frequent minor falls at home. His CT brain is reported as showing a right parietal infarct. What do you think might be a reason for his memory loss?

Patient has risk factors for vascular dementia (smoking, hypertension and right parietal infarct) which may be the reason for his memory loss. He also has history of multiple falls that can lead to series of minor stroke, leading to worsening of cognitive decline.

20. This picture (Question 20) shows the resting ECG of a 35 year old woman who underwent an Exercise Stress Test. The EST was negative for inducible myocardial ischemia. What do you see in the resting ECG that gives a clue to a cardiac illness she may have?

Q wave (>2mm) in lead III, V1,V5 and V6.

21. A 69 year old man with Diabetes, hypertension and CKD is on Insulin, Metformin, Metoprolol, Amlodipine, Losartan, Atorvastatin and Hydrochlorothiazide. He is noted to have hypokalemia (K 3.2mmol/L) and a raised serum ALT (61U/L). Which of his medications may be responsible for these abnormalities?

Hypokalemia: Insulin, Hydrochlorothiazide ; Raised serum ALT: Atorvastatin, Metoprolol (<1%), Amlodipine (<1%)

22. This is the blood test report of a patient with chronic kidney disease (Question 22). Based on the information in these reports, what can you say about the patient's serum parathyroid hormone levels? Is it likely to be low, normal or high?

Renal profile of this patient showed decreased calcium (2.18 mmol/L) and increased inorganic phosphate (2.36 mol/L). Liver function test revealed raised alkaline phosphatase (174 U/L) which could indicate an increase in bone turnover secondary to high PTH levels.

23. A 61 year old man has a fasting plasma glucose of 6.5mmol/L and a postprandial plasma glucose (at one and a half hours after breakfast) of 12mmol/L. His HbA1c is 6.6%. Does this patient have diabetes?

The diagnostic values for T2DM include fasting plasma glucose >7.0mmol/l and a random plasma glucose of >11.1mmol/l. I would have a look at his HbA1c value which shows his glucose control over the past 3 months. According to current Clinical Practice Guidelines, a HbA1c level of > 6.3% is diagnostic of T2DM.
Needs discussion

24. A pregnant woman has a fasting plasma glucose of 4.9mmol/L. Following oral intake of 75-gram glucose, her one-hour postprandial plasma glucose is 10.1mmol/L and and two-hour postprandial glucose is 8.7mmol/L. Is she diabetic?

Yes, patient is diabetic. A single positive result is sufficient to diagnose gestational diabetes mellitus (FPG >5.1mmol/l or 2 hour post prandial following 75gm oral glucose of >7.8mmol/l).
(Needs discussion)

25. A 69 year old man underwent an exercise stress test. He achieved 56% of his target heart rate and 7.1 METS of exercise. There were no ST segment changes of inducible myocardial ischemia during or after the EST. His EST was reported as negative for significant coronary artery obstruction. What is the error in the report?

Although adequate METS score is achieved, a minimum target heart rate of 80-85% is required for more accurate interpretation. That being said, negative EST does not necessarily indicate the absence of coronary artery disease.

26. A 51 year old man suffered an acute STEMI in January 2016. An Exercise Stress Test done in November 2016 was reported as positive for inducible myocardial ischemia. Why do you think the EST was done for this patient?

Goal of stress test post revascularisation is to evaluate for restenosis and to determine functional status and symptoms of patient. The patient may have symptoms of myocardial ischemia post STEMI thus warranting the exercise stress test to be done. Also, the STEMI incident in January may be a silent ischemia where PCI or CABG were done for him. An exercise stress test post revascularisation is indicated in this case to monitor progression or restenosis of coronary vessels.
(Needs discussion)

27. A 67 year old man with severe CAD, poor LV function, developed atrial fibrillation. His ECG showed irregularly occurring broad QRS complexes. Suggest a reason for the broad QRS complexes.

The broad QRS complexes could be due to a bundle branch block as the patient has severe coronary artery disease.

28. A 63 year old man with CAD, COPD, atrial fibrillation, mitral regurgitation and chronic kidney disease is prescribed Verapamil. What do you think is the indication for Verapamil?

Coronary artery disease is an indication for verapamil. Verapamil helps promote coronary vasodilation , reduces myocardial oxygen demand and relieves symptoms of angina. Since this patient also has atrial fibrillation , verapamil can also be given for rate control if the patient is above the 65 , has preexisting coronary artery disease and is unable to tolerate other anti-arrhythmic drugs / cardioversion.
(needs discussion)

29. A 55 year old woman with diabetes and hypertension developed sudden loss of vision in both eyes 3 months ago. She recovered her sight within 4 hours. Her CT brain showed a lacunar infarct on the right lentiform nucleus and external capsule. Can this infarct be the cause of her loss of vision?

Lacunar infarct is unlikely to be the cause of her visual loss. Unlike cortical strokes , lacunar strokes do not (almost never or rarely) cause visual symptoms as they usually present with pure hemiparesis or hemisensory loss. The infarct may well be attributed to a previous history of lacunar stroke. Thus , I would probably consider other causes of sudden visual loss such as central retinal artery or vein occlusion and ischaemic optic neuropathy.
(Needs discussion)

30. A 55 year old woman with DM and HPT is on Insulin, Metformin, Perindopril, Amlodipine, Atorvastatin and Aspirin.She is well and without symptoms. During her scheduled review in the clinic, her serum creatinine is noted to be elevated at 134umol/L (normal is less than 120umol/L). Explain how you will interpret the elevated serum creatinine.

Elevated serum creatinine in her case may be due to a side effect of perindopril. Perindopril can cause a transient increase in creatinine. Depending on her baseline creatinine level, an increase within 25% of baseline is considered normal. Another possible reason for elevated creatinine is long standing diabetes and hypertension causing renal impairment.

31. A 69 year old woman with diabetes, hypertension and ESRF on maintenance hemodialysis is noted to have elevated serum parathyroid hormone levels with normal serum calcium values. Explain why the PTH is elevated in spite of a normal serum calcium level.

This patient with end-stage renal disease may have developed tertiary hyperparathyroidism as a consequence of long-standing secondary hyperparathyroidism. In tertiary hyperparathyroidism , the parathyroid glands become autonomous , producing excessive PTH even after the cause of hypocalcemia has been corrected. This explains why the PTH is elevated despite a normal (or increased) serum calcium level.

32. A 56 year old man with a congenital heart disease was diagnosed to have a ventricular septal defect with pulmonary stenosis in a district hospital. At a tertiary cardiac centre he was diagnosed to have tetralogy of Fallot (TOF). What do you think was present in this patient for the diagnosis to be changed to TOF?

TOF is generally diagnosed based on a combination of ventricular septal defect, over-riding of aorta, right ventricular outflow tract obstruction and resultant right ventricular hypertrophy. These findings on 2-dimensional transtroracic echocardiogram and Doppler ultrasound are diagnostic for Tetralogy of Fallot.

33. A 70 year old man with HPT and Thyrotoxicosis has been on treatment with Carbimazole for many years. His thyroid function test currently shows serum T4 19.87pmol/L (normal 9.14 to 23.8) and serum TSH 0.019mIU/L (0.23 to 3.8). What is your advice regarding his treatment for thyrotoxicosis?

Response 1: The above serum T4 and serum TSH level shows subclinical hyperthyroidism. The dosage of the medication should be adjusted until the patient is clinically and biochemically euthyroid. In view of the fact that he is subclinical hyperthyroid despite being given carbimazole for many years, more treatment options such as radioiodine and surgery should also be offered.
Response 2: I would like to repeat the biochemical investigations in 2-4months time to distinguish between persistent and transient subclinical hyperthyroidism. Meanwhile, the patient should continue taking Carbimazole.

34. A 52 year old man with DM and HPT and an old R hemiplegia is on treatment with Inj Mixtard insulin 18units sc BD. His current glycosylated hemoglobin is 9%. What is your advice regarding his diabetes?

Response: The patient's fasting blood sugar level should be tested and, if it is abnormal (above 7mmol/L), the night dose should increase by 2 units. However, if the fasting glucose value is normal, he should be requested to take a pre-breakfast, pre-lunch and pre-dinner capillary blood glucose….in order to see at which point the plasma glucose is high.Moreover, this man should be counselled on the importance of diabetic control, and referral to the dietitian if required.

35. A 69 year old woman was earlier diagnosed to have megaloblastic anemia. She was treated with injections of Vit B12 and her hemoglobin levels improved. Right now she is on oral generic B complex tablets and oral folic acid tablets. What concerns do you have regarding her treatment?

Response: Pernicious anemia has to be considered. In the absence of intrinsic factors, absorption of oral vitamin B12 supplementation is impaired. Absorption of oral vitamin B12 by passive diffusion only accounts for 1% of total absorption and is inadequate for the body. Very high dose is needed to achieve a small rise in serum Vitamin B12. Sublingual or intramuscular route of Vitamin B12 is preferred to bypass the digestive system. With supplementation of folic acid alone, patient can achieve hematological remission for megaloblastic anemia. However, it does not reverse neurological deficit caused by Vitamin B12 deficiency.

36. A 58 year old man with IHD is diagnosed to have obstructive coronary artery disease in the left anterior descending artery after undergoing coronary angiogram. What parameter can be used to decide whether that obstruction needs intervention?

Response: Left main coronary artery is >50% stenosed; 3- vessel disease with >70% stenosis each vessel; Left ventricular dysfunction

May 21st
37. Look at this ECG tracing (Question 37). What does the cardiac axis tell you?

Response 1: There is right axis deviation. It is most likely due to right ventricular hypertrophy evident by R>S wave in lead V1.
Response 2: The ECG shows a bifasicular block which is a combination of right bundle branch block and left anterior hemi-block. The right bundle branch block is denoted by RSR pattern in V1, deep and wide S wave in V5 and V6. Deep S waves in lead III and AVF typical for left anterior hemi-block.

38. Look at this X-ray of the chest (Question 38). It shows: Mediastinal widening due to dilated pulmonary arteries. What kind of disease do you think is responsible for this finding?

Response awaited

39. A 68 year old woman with diabetes, hypertension and history of having recovered from a stroke is on daily thyroxine tablets for treatment of hypothyroidism. She does not have a goitre. What could be the cause of hypothyroidism without a goitre?

Response: The patient could be having an autoimmune thyroid disorder known as Atrophic Thyroiditis (AT), characterized by thyroid autoantibodies, functional hypothyroidism and absence of goitre.

40. A 64 year old man with thyrotoxicosis was started on Carbimazole in January 2017. In March 2017 he was noted to be hypothyroid and his carbimazole treatment stopped. In May 2017, his thyroid function tests showed serum T4 31.81 pmol/L (normal 9.14 to 23.8) and serum TSH 0.08 mIU/L (normal 0.23 to 3.8) and he was restarted on Tab Carbimazole. What will you do if he develops hypothyroidism again in the next few months?

Response: I would continue the carbimazole medication, but at a lower dose and slowly titre until his thyroid function test shows euthyroid. Meanwhile while adjusting the dosage, I would monitor his thyroid function every 6-8 weekly

41. A female patient in the clinic recently complained to her doctor that she was not sleeping well after having suffered a mild stroke (from which she has recovered well). The doctor inquired about depressive symptoms in her, which she denied having. What is the basis for suspecting depression in people like her?

Response: The basis for suspecting depression in this patient is due to the episode of stroke which has occurred as stroke patients are at a high risk of developing depression. She also complaint of not being able to sleep well, indicating presence of sleep disturbances, either difficulty falling asleep or early morning awakenings, which is one of the common complaints in patients suffering from depression.

4th June
42. A 71 year old woman with DM, HPT and CAD is on Atorvastatin 20mg ON along with other medicines. Her lipid profile shows: Total cholesterol 3.9mmol/L, Triglycerides 1.7mmol/L, HDL cholesterol 0.8mmol/L and LDL cholesterol 2.3mmol/L. Do you have any comments regarding her lipid profile?

Response awaited

43. A 54 year old man had been admitted in hospital on 3 occasions in 2016. His discharge diagnosis on these occasions are: Nov 2016: Decompensated CCF. Atrial fibrillation. Mitral regurgitation. Hyperthyroidism; June 2016: Valvular cardiomyopathy; Hyperthyroidism. Mitral regurgitation. Atrial fibrillation; Jan 2016: Decompensated CCF. Mitral regurgitation. Hyperthyroidism. Atrial fibrillation. If you are told that his ECG shows no ischemic changes, his x-ray chest shows cardiomegaly and his ECHO shows all chambers dilated with global hypokinesia and LVEF of 35%, what will you attribute his mitral regurgitation and CCF to?

Response awaited

44. Explain what you will tell the following patients about their diabetic treatment when they begin fasting during the approaching month of Ramadan. Patient A: 68 year old woman with diabetes who is on Tab Gliclazide 40mg BD and Tab Metformin 500mg BD. Her fasting plasma glucose with this treatment is 6.3mmol/L. Patient B: 18 year old boy with diabetes on Injection Mixtard insulin 30 units before breakfast and 16 units before dinner plus Injection Actrapid insulin 8 units before lunch. His glycosylated hemoglobin is 7 percent (Suggested references: this and this).

Response awaited

A template for learning how to write clinical summaries for Semester 10 students

Dr Velayudhan Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia

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