Laboratory interpretation of renal function test, liver function test and thyroid function test along with their clinical significance

this slide renal function test, liver function test and thyroid function test laboratory interpretation of them including their clinical significance

1. Presented by Parbati Chaudhary RENAL FUNCTION TEST, THYROID FUNCTION TEST, LIVER FUNCTION TEST & THEIR CLINICAL SIGNIFICANCE. Masters In Clinical Pharmacy, PUSHS Renal function test, Thyroid function test, Liver function test & their clinical significance.

2. Renal Function Test Liver Function Test Thyroid Function Test Case Studies. Today's Topics Presentation Outline

3. NEXT •To assess functional capacity of kidney. •To diagnose renal impairment. •To assess the severity and progression of renal impairment. •To assess the effectiveness of treatment. RENAL FUNCTION TEST Laboratory test done to evaluate renal function to aid in renal disorder diagnosis. Importance:

4. NEXT •Edema. •Irregular urine output. •Before major surgery. RENAL FUNCTION TEST When kidney function test done?

5. Classification of renal function test

6. NEXT Urine Analysis. Serum Creatinine. Serum Electolytes. Routine analysis

7. NEXT 1.Physical Examination. 2.Chemical Examination. 3.Microscopic Examination. URINALYSIS •Involves testing and reporting of urine sample. •Commonly used as first clinical test for the evaluation of various renal and nonrenal problems (e.g., endocrine, metabolic, and genetic) Standard urine analysis includes:

8. NEXT 1.Physical Examination 24 Hour urinary out put(volume). Appearance (color). Odor.

9. NEXT •Water intake. •External temperature. •Diet. •Mental and physical state. •Cardiovascular and renal function. 1.Physical Examination 24 HOUR URINARY OUT PUT(VOLUME). Normal daily out put range in adult: 800-2500 ml with average of 1500 ml/day. Depends on:

10. •Water intake External Temperature •Diet Mental and physical state •Cardiovascular and renal function & NEXT

11. NEXT • Polyuria: > 2500 ml/day •Diabetes mellites: Up to 5-6 l/day • Diabetes insipidus: 10-20 l/day •Oliguria: up to 500 ml/day due to fever, diarrhea, acute nephritis, early stage of glomerulonephritis, cardiac failure •Anuria: <100 ml urine seen in acute tubular necrosis, bilateral renal stones, surgical shock Clinical Significance:

12. NEXT 1.Physical Examination Appearance (color).

13. NEXT 1.Physical Examination Odour. Normal odour: aromatic Foul smell : bacterial infection Chemical examination using dipstick :

14. NEXT Chemical Examination:

15. NEXT Microscopic Examination:

16. NEXT •Urea is an end product of protein catabolism produced in liver by means of urea cycle and excreted by Kidneys. •It is filtered at glomerulus and passively reabsorbed in both PCT and DCT. •Under normal condition, urea clearance is about 60% Of true GFR. •Normal serum urea level: 20-40 mg/dl. •It increases only if glomerular function is reduced below 50% a.Serum Urea

17. NEXT •Blood urea nitrogen (BUN) is the concentration of nitrogen (as urea) in the serum . •It is calculated by multiplying serum urea level by 0.47 •Normal range: 8-18 mg/dl BUN/Creatinine ratio >20; suggests prerenal cases e.g.GI bleeding. BUN/Creatinine ratio <20; intrinsic renal disease Blood urea nitrogen

18. NEXT Elevated BUN (Azotemia) 1.Pre renal: Decreased plasma volume, decreased renal perfusion leading to urea retention. Acute intestinal obstruction – Severe and prolonged vomiting. Severe diarrhea. Pyloric stenosis with severe vomiting. Ulcerative colitis with severe chloride loss. Diabetic Ketoacidosis. Shocks, severe burns and hemorrhage. Salt and water depletion Hematemesis In crisis of Addison’s diseases Increased protein catabolism:- Fever, Thyrotoxicosis, Cardiac failure Clinical Significance:

19. NEXT Clinical Significance: 2. Renal Disease: Renal Disease: Blood urea is increased in all forms of renal diseases like; •Acute glomerulonephritis. •Renal failure •Malignant hypertension •Malignant nephrosclerosis •Hydronephrosis •Chronic pyelonephritis •Congenital cystic kidneys •Over use of nephrotoxic drugs such as corticosteroid, tetracycline, NSAIDs ACE inhibitors, Acetaminophen, Aminoglycosides, Amphotericin B, Diuretic and so on.

20. NEXT 3. Post Renal Disease: Due to obstruction to flow of urine, retention seen and so reduction in effective filtration pressure at the glomeruli; when prolonged effects produce irreversible kidney damage. • Enlargement of prostrate. •Obstruction of ureter, bladder, neck or urethra •High protein diet •UTI •Upper GI bleeding Clinical Significance:

21. NEXT Clinical Significance: Decreased BUN: It is rare but may be seen. •In some cases of severe liver damage. •Physiological condition- Blood urea has been seen to be lower in pregnancy than in normal non pregnant. •Low protein diet.

22. NEXT •Creatinine is the by-product of creatine phosphate in muscle, and it is produced at a constant rate by the body. •It is more sensitive and specific indicator of renal damage than BUN levels. •Normal range: •Male: 0.6-1.2 mg/dL •Female: 0.5-1.1 mg/dL •Creatinine levels above the normal range correlate with a reduction of GFR and indicate renal dysfunction. Serum Creatinine:

23. NEXT Elevated level: • Renal dysfunction • Dehydration • UT obstruction • increased exercise • hyperthyroidism • myasthenia gravis • drugs: cisplatin/ amphotericin B Clinical Significance: Decreased Level • cachexia • inactive elderly • comatose patients • spinal cord injury patients

24. NEXT Electrolytes frequently used to screen for an electrolyte or acid-base imbalance and to monitor the effect of treatment on a known imbalance that is affecting bodily organ function. Sodium (Na) Normal range: 135-147 mEq/L or mmol/L Serum electrolytes:

25. NEXT Hypernatremia • Dehydration, • impaired Na excretion, • Gastroenteritis (severe vomiting, diarrhea), • DM (poorly controlled case), • DI (dilute urine production), • Drugs; Lithium, Colchicine, • may cause CNS pathology Clinical Significance: Hyponatremia • Lethargy/nausea/drowsiness/confusion) Overhydration, • salt wasting nephropathy, • Syndrome of inappropriate antidiuretic hormone ADH release (SIADH) (seen with lung cancer/ COPD/TB/ Stroke), • CCF, Renal Failure, Nephrotic syndrome, • Drugs: SSRIs/Antidepressants/Narcotics (cause SIADH)

26. NEXT Potassium (K) • Most convincing electrolyte marker of renal failure. • The combination of decreased filtration and decreased secretion of potassium in distal tubule during renal failure cause increased plasma potassium. • Hyperkalemia is the most significant and life-threatening complication of renal failure . • Normal range: 3.5-5.0mEq/L or mmol/L . Serum electrolytes:

27. NEXT Hyperkalemia • renal elimination, • from cellular breakdown (tissue damage, hemolysis, burns, infection), • Drugs: K sparing diuretics, ACEIS,NSAIDs, • Acute renal failure, • Addison’s disease • Metabolic/Respiratory acidosis (shifts K in ECF) Clinical Significance: Hypokalemia • malaise, • confusion, • dizziness, • muscle and knee pain • Vomiting, diarrhea, • Gastric suction, • Drugs: thiazides, loop/osmotic diuretics, digoxin laxatives, • Alkalosis, hyperaldosteronism, Cushing’s disease

28. NEXT 1.To assess glomerular function a. Glomerular permeability: Proteinuria b. Glomerular filtration rate: Clearance( creatinine, inulin, urea) 2.To assess tubular function a. Concentration & dilution tests b. Renal acidification B. To assess renal function a.Glomerular permeability: Proteinuria: •Presence of protein in urine in excess than normal range. •Normal: <150 mg of protein and <30 mg of albumin in 24 hr. urine sample. •Not detectable by routine tests. •Indicator of leaky glomeruli and first sign of glomerular injury before decrease in GFR. •Most common cause: los of integrity of glomerular basement(glomerular proteinuria) seen in nephropathic syndrome and diabetic nephropathy. •Common types: I.Glomerular Proteinuria II.Microalbuminuria

29. NEXT I .Glomerular Proteinuria • Plasma proteins are absent in normal urine as glomeruli of kidney are not permeable to it. • In damaged case of glomeruli, Its permeability increases ,appearance of plasma protein in urine. • The smaller molecules of albumin pass throughdamaged glomeruli more readily than the heavier globulins. • Sample used: Overnight first voided sample i.e. early morning urine-(EMU) • Detection limit with Dipstick is 200–300 mg/L. To assess glomerular function Clinical significance •300 mg/day = Benign proteinuria •300 mg – 1000 mg = Pathological proteinuria •> 1000 mg/day = Glomerular proteinuria •Determine earliest sign of almost all renal diseases by presence of significant amount of protein in urine . •Helps in differentiating between tubulointerstitial and glomerular diseases • To follow the progress of renal disease and •To assess the response to therapy. . •Proteinuria more than 3.5 gm/day is taken to be diagnostic of nephrotic syndrome.

30. NEXT II. Microalbuminuria •Presence of small quantity of albumin (30–300 mg/day) in urine. •Not indicated in patients with overt proteinuria (+ve dipstick). •Albuminuria is always pathological •Sample used: Early morning midstream sample. •The test should be done at least once in an year. To assess glomerular function Clinical significance •An early indication of nephropathy in patients with diabetes mellitus and hypertension. So, all patients of diabetics and hypertensive should be screened for microalbuminuria. • Early indicator of nephropathy.

31. NEXT b.Glomerular filtration rate: • Normal GFR for young adults : 120–130 mL/mt/1.73M^2. • "A decline with age is significant and more than 25% of people older than 70 years may have a GFR less than 60 mL/min." To assess glomerular function Clearance tests : •Predominant test of glomerular filtration rate (GFR). •Provides the most useful general index for the assessment of the severity of renal damage. •Estimates the amount of plasma that must have passed through the glomeruli per minute with complete removal of that substance to account for the substance actually appearing in the urine. Clearance= (mg of substance excreted per minute) (mg of substance per ml of plasma ) 〖Cl〗_cr=(U×V)/P,"Where,Clcr = clearance, U = urinary concentration, V = urinary flow rate (volume/time i.e., ml/min),P = plasma concentration "

32. NEXT Clearance test S ubstance used in clearance tests are: • Endogenous creatinine and inulin • Exogenous urea Test done in : • Patients starting dialysis; • In the presence of acute changes in kidney function in hospitalized patients (e.g., acute kidney injury, acute renal failure) or with comorbid medical conditions; • During evaluation of dietary intake; • Patients with extremes in muscle mass; • Health enthusiasts taking creatine supplementation; • Vegetarians;

33. NEXT Types: i. Creatinine clearance test ii. Inulin clearance test ( gold standard for clearance test as freely filtered, not reabsorbed or secreted but expensive, invasive, difficult to assay) i. Urea clearance test BIOTIN BENEFITS | AMC

34. NEXT •Provides an estimate of the GFR. •Helps in early detection of renal failure. •Sample used: 24/ 12 hour collected urine. • Normal range: • Male: 110- 150mL/min • Female: 100-130mL/min •Decreased creatinine clearance is a very sensitive indicator of decreased GFR which may be caused by acute or chronic damage to the glomerulus or any of its components. i.Creatinine Clearance test CLINICAL SIGNIFICANCE Decrease in GFR level: •Acute tubular necrosis •Glomerulonephrosis •Acute nephrotic syndrome •Acute and chronic renal failure

35. 2.To assess tubular function •Tubular function tests involve: •Evaluation of functions of the proximal tubule (i.e. tubular handling of sodium, glucose, phosphate, calcium, bicarbonate and amino acids) and distal tubule (urinary acidification and concentration). •Assessment of the concentration and diluting ability of the kidney. •Test: a. Concentration & dilution tests b. Renal acidification

36. Concentration test •Measured using specific gravity and osmolality test. •Measurement of urine osmolality allows for assessment of concentrating ability of urine tubules. •A urinary osmolality higher than 750 mOsmol/Kg H2O implies a normal concentrating ability of tubules. •Simplest test of tubular function. •Specific gravity is measured after a 12 hr fast •Normal range= 1.05-1.025 1.010:for chronic renal failure. •Specific gravity > 1.022 shows adequate renal function. •In normal persons, it may be as high as 1.032. •With progress of disease, the urine specific gravity is fixed at1.010 (300 mOsmol/kg)) i.e. isosthenuria and seen in chronic renal failure. •The measurement of the volume of urine excreted during the day and the night is another simple index of tubular function. Normally, night volume is only half of the day volume. So, Nocturia denotes tubular dysfunction.

37. LOW SPECIFIC GRAVITY: Diabetes insipidus Renal failure Pyelonephritis Glomerulonephritis Psychogenic polydipsia Malignant hypertension. Clinical significance BIOTIN BENEFITS | AMC •Assess concentration ability of the kidney as the earliest manifestation of renal disease may be difficulty in concentrating the urine. HIGH SPECIFIC GRAVITY: Hepatorenal syndrome Heart failure Renal artery stenosis Shock Syndrome of inappropriate antidiuretic hormone

38. NEXT Dilution test •Assess ability of kidney to eliminate water. • More sensitive and less harmful than concentration test. Method: •Bladder is emptied at 7 AM and a water load is given (1200 mL over the next 30minutes). •Hourly urine samples are collected for the next 4 hours separately. •Volume, specific gravity and osmolality of each sample are measured. •A normal person will excrete almost all the water load within 4 hours and •The specific gravity of at least one sample should fall to 1.003.

39. NEXT Urinary acidification: •The most useful test is acid loading test. •To check ability of kidney to produce acid. • It is indicated in unexplained hyperchloremic metabolic acidosis. •Test method: •Give ammonium chloride at a dose of 0.1 g/kg body weight. • The ammonium chloride (NH4Cl) is dissociated into NH4+ and Cl–. •In the liver the NH4+ is immediately converted into urea. • So, Cl– ions are counter balanced by H+ to produce HCl, a powerful acid. •It is then excreted through urine so as to produce acidification. • Sample: Urine is collected hourly, from 2 to 8 hours after ingestion. •The pH and acid excretion of each sample is noted. •At least one sample should have a pH of 5.3 or less. •In renal tubular acidosis, the pH 5.3 is not achieved. • Contraindication: liver disease

40. Water Break

41. Tests more specific for thyroid status or function can be categorized as those that: Measure the concentration of products secreted by the thyroid gland, Evaluate the integrity of the hypothalamic-pituitary-thyroid axis, Assess intrinsic thyroid gland function, and Detect antibodies to thyroid tissue. Tests included are: T3 resin uptake Thyroxine binding globulin Thyrotropin releasing hormone Thyroglobin Anti-thyroid antibody Thyroid stimulating hormone (TSH) Free Thyroxine Free(T4) Total serum T4 Total serum T3 15 min THYROID FUNCTION TEST: Rarely performed Commonly performed 41

42. 15 min Thyroid stimulating hormone Initial screening test for suspected patient with thyroid disease as it is the key hormone for diagnosing hyperthyroidism and hypothyroidism as it is central to the negative feedback mechanism and tiny variation in thyroid function causes dramatic changes in TSH secretion. Principal test for the evaluation of thyroid function in the vast majority of circumstances provided there is no clinical or historical evidence to suggest damage or disease of the hypothalamic-pituitary axis. Serum TSH normally exhibits a diurnal variation with a peak shortly after midnight and a nadir in the late afternoon. At the peak of this variation the TSH can be double the value at the nadir. TSH values can be expected to vary by as much as 20% between measurements without any change occurring in thyroid status. Further tests are added i.e.FT4, FT3, TSH receptor antibodies and / or TPO antibodies when indicated. TSH: 0.3-5 µU/ml. 42

43. 25 min Specific gravity and osmolality high Low: first trimester of pregnancy (falsely elevated) Primary hypothyroidism Pituitary adenoma (TSH producing) Pituitary resistance to thyroid hormone (TSH, unreliable) Generalized thyroid hormone resistance Thyrotoxicosis from overly rapid correction of severe hypothyroidism with use of parenteral thyroxine Drugs: amiodarone Recovery phase after severe systemic illness Primary hyperthyroidism Pituitary/hypothalamic disease Prolonged thyrotroph cell suppression after recent hyperthyroidism in euthyroid or hypothyroid patient. Drugs, e.g., glucocorticoids, dopaminergic (dopamine/levodopa/bromocriptine) Non thyroidal illnesses: Severe Sepsis or Septic Shock,Cardiac Surgery, cirrhosis,Trauma Glucocorticoid Therapy Clinical significance 43

44. 15 min Free Thyroxine Tetraiodothyronine, also known as thyroxine or T4, constitutes more than 80% of the secreted hormone. Measure unbound fraction of T4. Most accurate reflection of thyrometabolic status. Low concentration of free T4 in the serum(<1% of total T4) makes accurate measurement a difficult process. So, Free T4 is assayed primarily when TBG alterations or non-thyroidal illness confound interpretation of conventional tests. T4 test should be performed: to optimizing thyroxine therapy in newly diagnosed patients with hypothyroidism and hyperthyroidism. to diagnose for secondary hypothyroidism and also in case of end organ thyroid hormone resistance. T4: : 0.9–2.3 ng/dL 44

45. 15 min Thyroxine TSH with FT4 is only required: when stabilising treatment of thyroid dysfunction (hyper- or hypo- thyroidism ) in pregnancy in patients with goitre in monitoring of secondary hypothyroidism due to pituitary disease. 45

46. 25 min Specific gravity and osmolality high Low: Hyperthyroidism Graves’ disease, Plummer’s disease (toxic thyroid adenoma), early phase of acute thyroiditis, Luft’s syndrome (Hypermetabolic Mitochondrial Miopathy - in some cases) Primary hypothyroidism (thyroid failure) more common in CKD. Secondary hypothyroidism (pituitary failure) Tertiary hypothyroidism (hypothalamic failure) Malnutrition, Cirrhosis, Medications: high doses of salicylates/phenytoin . Clinical significance 46

47. 15 min Total Serum Thyroxine T4 Standard initial screening test to assess thyroid function because of its wide availability and quick turnaround time. Measures Both bound and free T4. Normal Range: 5.5–12.5 mcg/dl High : Low: Hyperthyroidism Increase concentration of Thyroid binding protein Hypothyroidism Low concentration of thyroid binding protein. Non thyroid illness Clinical significance 47

48. 15 min Free T3 resin uptake: Indirectly estimates the number of binding sites on thyroid-binding protein occupied by T3. Referred as the thyroid hormone-binding ratio. Usually low, if concentration of thyroid-binding proteins is high. Used to calculate Free T4 index. Alterations occur in Hypo- and Hyperthyroidism, pregnancy, nephrotic syndrome, TBG excess or deficiency. Normal range: 25–38% High : Low: Hyperthyroidism Hypothyroidism Clinical significance 48

49. 15 min Free Thyroxine index (FTI) Product of total serum T4 multiplied by the percentage of T3 resin uptake: free T4 index = Total serum T4 (mcg/dL) × T3 resin uptake (%) Calculated estimate of free thyroid hormone Corrects for alterations in protein binding. An indirect measure of FT4 Normal range: 1–4 units High : Low: Hyperthyroidism Drugs: phenytoin or salicylates Hypothyroidism Clinical significance 49

50. 15 min Total Serum T3 Using RIA highly active thyroid hormone T3 is measured. Like T4, almost all of T3 is protein bound. Measures Both bound and free T3. Indicator of hyperthyroidism. Usually made to detect T3 toxicosis when T3, but not T4, is elevated. Total serum T3 are affected by alternation in serum TBG level and drug that affect binding to TBG such as Estrogens Heparin( ), corticosteroid, salicylates( ) Used mainly for evaluating thyrotoxicosis. Normal range: 80–200 ng/dL 50

51. 25 min Specific gravity and osmolality high Low: hyperthyroidism, Thyrotoxicosis , high doses of levothyroxine, pregnancy, oral contraceptives use hypothyroidism and malnutrition, medications: glucocorticoids and propranolol Clinical significance 51

52. 15 min Thyroglobulin protein made by thyroid cells; used as a tumor marker in differentiated thyroid cancer; measurements affected by the presence of Tg antibodies (Abs) Calcitonin Hormone produced by the thyroid parafollicular (C-cells) Used as a marker in medullary thyroid cancer. 52

53. 15 min Antithyroid antibodies: Proteins produced by the immune system that mistakenly attack the thyroid gland. Their presence often indicates an autoimmune thyroid disorder. Types: Thyroid Peroxidase Antibodies ( TPOAb ): Thyroid peroxidase, an enzyme crucial for thyroid hormone production. Commonly found in Hashimoto's thyroiditis (hypothyroidism). Thyrotropin Receptor Antibodies ( TRAb ): Target the TSH receptors on the thyroid gland. Associated with Graves' disease (hyperthyroidism ) Valuable only in hyperthyroid patients Thyroid-Stimulating Hormone Receptor Antibodies ( TSHRAb ) : These can either stimulate or block the TSH receptor on thyroid cells, leading to hyperthyroidism or hypothyroidism, respectively. 53

54. 25 min Specific gravity and osmolality Clinical significance 1.Hashimoto's Thyroiditis Anti- TPOAb and TgAb : High levels of these antibodies are commonly found in Hashimoto's thyroiditis, an autoimmune disorder leading to hypothyroidism. The presence of these antibodies suggests ongoing thyroid inflammation and damage. 2. Graves' Disease TSHRAb : These antibodies are typically found in Graves' disease, an autoimmune disorder causing hyperthyroidism. TSHRAb stimulates the thyroid gland to produce excess thyroid hormones. Ranges: Thyroid peroxidase antibody ( TPOAb ): Titer less than 9 IU/mL Thyroglobulin antibody ( TgAb ): Less than 116 IU/mL   Thyroid-stimulating immunoglobulin antibody (TSI): Less than 130% of basal activity   54

55. 25 min Specific gravity and osmolality Clinical significance 3. Subclinical Hypothyroidism Anti- TPOAb : Indicate a risk of developing hypothyroidism, even if thyroid function tests are currently normal. This is referred to as subclinical hypothyroidism . 4. Postpartum Thyroiditis Anti- TPOAb : Women with high levels of anti-TPO antibodies during pregnancy are at increased risk of developing postpartum thyroiditis, which can lead to temporary or permanent thyroid dysfunction. 5. Thyroid Cancer Monitoring TgAb : In patients treated for thyroid cancer, the presence of thyroglobulin antibodies can interfere with thyroglobulin measurement, which is used to monitor for cancer recurrence. Monitoring TgAb levels can help assess the risk of recurrence. 6. Other Autoimmune Diseases General Marker : The presence of anti-thyroid antibodies can also be associated with other autoimmune diseases, such as type 1 diabetes, rheumatoid arthritis, and lupus. 55

56. 15 min Clinical significance Cause Thyroid function tests TSH T4 T3 Iodine deficiency disorder increase decrease decrease Hasimoto’s thyroiditis increase Normal/decrease Normal/decrease Pituitary abnormality decrease decrease decrease Non-thyroid illness variable Normal/decrease decrease Grave’s disease decrease increase increase Hasimoto’s thyroiditis(early stage) decrease increase increase Clinical interpretation 56

57. 15 min LIVER FUNCTION TEST Set of laboratory investigations that provides information about the state of a patient's liver.  Determine an area of the liver where damage may be taking place and, depending on the pattern of elevation, can help organize a differential diagnosis. 57

58. 15 min LIVER FUNCTION TEST 58

59. 15 min LIVER FUNCTION TEST 59 Liver function tests can be used to: Screen for liver infections, such as hepatitis Monitor the progression of a disease, such as viral or alcoholic hepatitis, and determine how well a treatment is working Measure the severity of a disease, particularly scarring of the liver (cirrhosis) Monitor possible side effects of medication such as statins. An check up of diabetic patients. Assess coagulation disorder. Elevation of LFTs indicates damage (and to some extent, malfunction) of liver cells (hepatocytes) or the liver’s histological architecture (for example, the bile canaliculi

60. 15 min Types Tests to assess cholestatic disease and hepatocellular injury Liver Enzymes Alanine Transaminase (ALT) Aspartate Transaminase (AST) Alkaline Phosphatase (ALP) Gamma-Glutamyl Transferase (GGT) Lactate Dehydrogenase (LDH Serum Bilirubin Tests to assess liver synthetic function(protein synthesis) Total Serum Proteins Albumin Globulins Prothrombin Time (PT) The International Normalized Ratio (INR) 60

61. 15 min Types 61

62. 15 min A. Tests to assess cholestatic disease and hepatocellular injury Liver Enzymes Alanine Transaminase (ALT) Aspartate Transaminase (AST) Alkaline Phosphatase (ALP) Gamma-Glutamyl Transferase (GGT) Lactate Dehydrogenase (LDH Serum Bilirubin 1.Liver enzyme Hepatocytes contain high levels of enzymes that can leak into the plasma when there is liver injury. Enzymes found in hepatocytes are: Cytoplasmic = AST, ALT & Mitochondrial = AST m Liver enzymes are most useful in differentiating hepatocellular damage from cholestasis. Indicates only that the state of liver cell damage, don't assess the liver's ability to function. Measures catalytic activity rather than actual enzyme concentration 62

63. 15 min a. Lactate dehydrogenase Type of protein, known as an enzyme present in almost all metabolizing cells. It is found in almost all the body's tissues, including those in the blood, heart, kidneys, brain, and lungs. Plays a crucial role in cellular respiration by converting pyruvate, the end product of glycolysis, into lactate and back. Thus, produces energy for cells, especially under low oxygen conditions General marker of tissue damage rather than a specific diagnostic test. Isoenzymes: LDH1, LDH2: primarily in heart LDH3: primarily in lung LDH4, LDHS: primarily in liver and skeletal muscle (Liver disease: hepatitis/cirrhosis Normal range: 100-210 IU/L 63

64. 15 min Liver function test Clinical significance Diagnosis of tissue damage: Myocardial infarction (heart attack)   Liver disease (hepatitis, cirrhosis)   Hemolytic anemias (breakdown of red blood cells)   Muscle injuries (rhabdomyolysis)   Lung diseases (pneumonia, pulmonary embolism)   Kidney disease   Pancreatitis   Certain types of cancer (e.g., testicular cancer, lymphoma)   Monitoring disease progression: Cancer progression   HIV infection   Muscular dystrophy   Evaluating treatment effectiveness: Assessing the efficacy of treatments for other conditions involving tissue damage 64

65. 15 min Liver function test Previously known as SGOT (Serum Glutamic Oxaloacetic Transaminase) Mostly present in liver tissues, also found in heart, skeletal muscles, kidney tissue, pancreatic tissues. Often part of a routine blood screening to check the health of liver. Diagnose or monitor liver problems and diagnose other health conditions. Indicates hepatocellular injury and death. Plasma half-life- 17 hours Normal value: 0-40IU/L b. Aspartate aminotransferase 65

66. 15 min Liver function test Clinical significance Liver disease: In conjunction with alanine aminotransferase (ALT) to assess liver function. While both enzymes are elevated in liver damage, ALT is more specific to liver injury.   Cardiac damage : In heart attack, not specific as troponin for diagnosing myocardial infarction. Muscle damage: Conditions like rhabdomyolysis (breakdown of muscle tissue)   Other conditions: pancreatitis, kidney disease, and hemolytic anemia. AST to ALT Ratio: provide further insights into the underlying cause of liver disease. For e.g., a higher AST to ALT ratio is often seen in alcoholic liver disease Limitations of AST as a Diagnostic Marker Suggest only tissue damage, not the exact location of the injury. Other factors, such as strenuous exercise or hemolysis (breakdown of red blood cells during blood collection), can also increase AST levels. AST levels can fluctuate over time, making it difficult to interpret results without considering other clinical factors .. 66

67. 15 min c. Alanine Aminotransferase (ALT) Formerly known as SGPT (Serum Glutamic Pyruvic Transaminase), Found primarily in liver, also found in heart, skeletal muscle, and kidney. When liver cells are damaged release ALT into the bloodstream high levels of ALT in blood may be a sign of a liver injury or disease Plasma half-life: 47 hours Normal values: 0-35 IU/L 67

68. 15 min Liver function test Useful in early diagnosis to evaluate severity and prognosis of liver diagnose , to monitor the course of treatment for hepatitis, active post-necrotic cirrhosis, and the effect of drug therapy. Increased ALT levels are found in the following conditions: Hepatocellular disease Active cirrhosis (mild increase) Metastatic liver tumor Obstructive jaundice or biliary obstruction (mild to moderate increase) Viral, infectious or toxic hepatitis (30-50x normal) Lack of blood flow to the liver Certain medicines (penicillin, ciprofloxacin, tetracycline, sulphonyl ureas , NSAIDS etc.) or poisons Clinical significance 68

69. 15 min Liver function test Clinical significance 69

70. 15 min d. Alkaline Phosphatase(ALP)  A group of isoenzymes, located on the outer layer of the cell membrane. Produced primarily in liver and bones. An alkaline phosphatase test is often used to screen for or help diagnose diseases of the liver or bones. Used as screening test rather than specific diagnostic test. Alkaline phosphatase levels estimate the amount of impedance of bile low. Normal range: 44-147 IU/L 70

71. 15 min Liver function test Clinical significance Liver Disease: Obstructive biliary diseases (gallstones, bile duct cancer)   Hepatitis (viral, alcoholic, or drug-induced) Cirrhosis Liver cancer Bone Disorders: Indicator of bone-related issues, including: Bone growth (especially in children and adolescents)   Paget's disease (a bone disease) Osteomalacia (soft bones due to vitamin D deficiency) Osteogenic sarcoma (bone cancer)   Other Conditions: less common Pregnancy   Hyperthyroidism Certain types of cancer (e.g., germ cell tumors) 71

72. 15 min Liver function test Low levels of ALP : less common, sign of a lack of zinc, malnutrition, pernicious anemia, thyroid disease, Wilson disease or hypophosphatemia, a rare genetic disease that affects bones and teeth. Limitations of ALP as a Diagnostic Marker factors, such as rapid bone growth (in children), pregnancy, or certain medications, can also increase ALP levels.   ALP levels can fluctuate over time, making it difficult to interpret results without considering other clinical factors 72

73. 15 min e. Gamma glutamyl transferase (GGT) Enzyme An enzyme majorly found in the liver.  Crucial role in the metabolism of glutathione and the transfer of amino acids across cellular membranes Damage to liver or bile duct causes GGT levels increase in the bloodstream Normal range: 0-30 IU/L Clinical significance Liver damage: Elevated GGT levels often indicate liver damage or disease, such as: Alcoholic liver disease   Bile duct obstruction   Hepatitis Cirrhosis   Differentiating liver and bone conditions: distinguish between liver and bone as the source of elevated alkaline phosphatase, another liver enzyme.   Monitoring alcohol consumption: Detecting drug-induced liver injury: such as phenytoin, barbiturates 73

74. 15 min 2. Serum bilirubin Breakdown product of heme pigments, which are large, insoluble organic compounds Marker of overall liver function. Serum bilirubin helps: To find out if there is a blockage in the bile ducts, the tubes that carry bile from your liver. To check on an existing liver disease or disorder. To diagnose disorders related to problems with breaking down red blood cells. Elevated bilirubin causes abnormal yellow coloration of the skin and sclera of the eyes (collectively, these symptoms are referred to as jaundice or icterus ). Excess carotenes (as due to large amounts of carrot consumption) may cause a similar effect on the skin but spare the eyes. Normal range: Total ( conjugated+unconjugated ): 0.1-1.0 mg/dl Direct (conjugated only): 0.1-0.4 mg/dl Indirect( unconjucated ): 0.2-0.7 mg/dl 74

75. 15 min Liver function test Clinical significance A. Elevated Bilirubin Levels : Increased unconjugated bilirubin: Pre-hepatic jaundice: Increased production of bilirubin (e.g., hemolytic anemia). Hepatic jaundice: Impaired conjugation of bilirubin (e.g., Gilbert's syndrome, Crigler -Najjar syndrome Neonatal jaundice (common in newborns)   Increased conjugated bilirubin: Hepatic jaundice: Impaired excretion of bilirubin (e.g., hepatitis, cirrhosis). Post-hepatic jaundice : Obstruction of bile flow (e.g., gallstones, pancreatic cancer). B. Decreased Bilirubin Levels : less common, Hemorrhage Overactive spleen Rare genetic disorder 75

76. 15 min B. Test to assess liver synthetic function( protein synthesis Total Serum Proteins Albumin Globulins Prothrombin Time (PT) The International Normalized Ratio (INR) 1.Total Serum Protein Refers to sum of albumin and globulin Any symptoms increase either albumin/ globulin also increases total protein Its value is limited if albumin and globulin results are already known Normal ranges: Total serum proteins: 5.5-9 gm/dl Albumin: 3.5-5.0 g/dl Globulins: 2.5-35. g/dl 76

77. 15 min Hyperproteinemia: Collagen vascular diseases (lupus, RA, scleroderma), sarcoidosis, multiple myeloma, dehydration. Hypoproteinemia: Results from liver disease (decreased ability to synthesize protein), renal disease (nephrotic syndrome, third degree burns etc where protein wasting occurs). Clinical significance 77

78. 15 min a. Albumin Quantitatively the most important protein synthesized( AA derived from gut/breakdown of RBC) in the liver, with 10–15 g/day being produced in a healthy man. Major plasma protein that is involved in maintaining plasma oncotic pressure preventing fluid from leaking out of blood vessels & the binding and transport of numerous hormones, anion drugs and fatty acids. Reference range: 3.5-5 gm/dl Serum half life: 20 days. Albumins measurements are slow to fall after the onset of hepatic dysfunction due to long half –life(4% degradation daily) Complete cessation of albumin production results in only 25% decrease in serum concentration after 8 days. 78

79. 15 min Liver function test : Clinical significance Hypoalbuminemia Hyperalbuminemia: May occur in hepatocellular disease cirrhosis Malnutrition, malabsorption, overhydration, nephrotic syndrome, ascites, hemorrhage , protein losing enteropathy, burns and chronic illness. High concentration of ionized (nonprotein bound, physiologically active) calcium in the bloodstream. This must be taken into account when interpreting the total serum calcium level Rare and can be iatrogenic, for example, inappropriate infusion of albumin, or Shock Dehydration, Anabolic steroids such as Danazol  . 79

80. 15 min b. Globulin Clinical significance Hepatocellular dysfunction does not lower globulin concentration unless associated with malabsorption. In primary biliary cirrhosis – Increase in IgM Alcoholic patients – increase IgA Elevated alpha-1 globulin: inflammatory conditions or liver disease. Elevated alpha-2 globulin: nephrotic syndrome or inflammatory condition Elevated beta globulins: liver disease or dyslipidemia. Elevated gamma globulins: chronic infections, autoimmune diseases, or multiple myeloma. Heterogeneous group of proteins divided into alpha-1, alpha-2, beta, and gamma globulins. Alpha and beta globulins primarily transport substances like lipids, iron, and copper. Gamma globulins are immunoglobulins (antibodies) involved in immune response Synthesised by T lymphocytes: Ig – IgA, IgD , IgE , IgG and IgM Reference range: 2 - 3gm/dl 80

81. 15 min 2.Prothrombin Time Blood test that measures how long it takes for blood to clot. It assesses the function of the extrinsic and common pathways of the coagulation cascade. Measures activity of Fibrinogen, Prothrombin, Factors V, VII and X but is not specific for liver disease. Normal range: 10 -13 seconds Clinical significance Increased Prothrombin time Cholestasis Vitamin K deficiency Injection of 10 mg Vit K corrects the coagulation abnormality in few days. If PT remains prolonged despite parenteral vitamin K (10mg), it is considered a sign of substantial hepatic dysfunction 81

82. 15 min 3.International Normalized Ratio Provides a more accurate and consistent measure of clotting time. Standardized version of PT that accounts for variations in different laboratories. Normal range: For healthy people:1.1 or below On warfarin medication:2.0- 3.0 with artificial heart valves :2.5 - 3.5 Clinical significance 82

83. 15 min 3.International Normalized Ratio Clinical significance Monitoring anticoagulant therapy : to monitor the effectiveness of anticoagulant drugs like warfarin. Too low INR: Increases the risk of blood clots, which can lead to heart attack, stroke, or pulmonary embolism.   Too high INR: Increases the risk of bleeding.   Assessing liver function : While not as specific as other liver tests, an elevated INR can indicate liver disease as the liver produces clotting factors. Evaluating bleeding disorders : An abnormally high INR can suggest a bleeding disorder, though other tests are typically needed for diagnosis. Pre-surgical assessment : Checking INR before surgery helps determine the risk of excessive bleeding. 83

84. Liver test Indications Typical and atypical ranges ALT test A higher result than typical on this test can be a sign of liver damage. Very high levels   over 1,000 units per liter (U/L) are most often caused by viral hepatitis, ischemic hepatitis, or injury from drugs or other chemicals. An  ALT above 25 international units per liter (IU/L)  in females and  33 IU/L in males   typically requires further testing and evaluation. AST test A high result on an AST test might indicate a problem with your liver or muscles. Elevated AST without elevated ALT may indicate heart or muscle disease. If ALT, bilirubin, and ALP are also elevated, it may indicate liver damage. The typical range for AST is usually up to  36 U/L  in adults and  may be higher   in infants and young children. ALP test High levels of ALP may indicate liver inflammation,  blockage of the bile ducts , or bone disease. Children and adolescents may have  elevated levels of ALP Trusted Source  because their bones are growing. Pregnancy can also raise ALP levels. The typical range for ALP in adults is usually  20–140 IU/ LTrusted Source . Albumin test A low result on this test can indicate that your liver isn’t functioning properly. This occurs in diseases such as  cirrhosis ,  malnutrition , and  cancer . The typical range for albumin is  35–50 grams per liter (g/L) . However, low albumin can also be a result of poor nutrition, kidney disease, infection, and inflammation. Bilirubin test A high result on the bilirubin test may indicate that the liver isn’t functioning properly. Elevated bilirubin levels with elevated ALT or AST may suggest cirrhosis or hepatitis. The typical range for total bilirubin is  usually 0.1–1.2 milligrams per deciliter (mg/ dL ). I nterpreting the results of a liver function test 84

85. This Photo by Unknown Author is licensed under CC BY-SA 85

86. Marie M., a 35-year-old housewife complains of nervousness, weakness, and palpitations with exertion for the past 6 months. Recently, she noticed excessive sweating and wanted to sleep with fewer blankets than her husband.She has lost 15 pounds over the last 6 months in spite of eating twice as much as she did one year ago. Her menstrual periods have been regular with less bleeding. Her HR is 96 beats/min and BP is 150/90 mm Hg. She appears anxious. She has smooth, warm, moist skin; a fine tremor ; and she cannot rise from a deep knee bend without aid . Upon physical exam, her thyroid contains three nodules—two on the right and one on the left with a total gland size of 60 g (three times normal size). All nodules are firm consistency, and there is no lymphadenopathy . Case Presentation 86

87. Test Result Reference Range Sodium 145 mEq /L 136–142 mEq /L Potassium 4 mEq/L 3.8–5 mEq/L Chloride 101 mEq /L 95–103 mEq /L Carbon dioxide 26 mEq /L 21–28 mEq /L BUN 10 mg/dL 8–23 mg/dL SCr 0.8 mg/dL 0.6–1.2 mg/dL Hgb 12 g/dL 12–16 g/Dl Hct 36% 36–45% RBC count 3.5 M/mm3 4–5.2 M/mm3 Antithyroid antibodies 1:200 MCV 104 mm3 80–100 WBC count 16 × 103 cells/mm3 4.8–10.8 × 103 cells/mm3 Calcium 9 mg/dL 9.2–11 mg/dL Glucose 96 mg/dL 70–110 mg/dL Free T4 15.6 ng/dL 0.9–2.3 ng/dL TSH 0.3 microunits/mL 0.5–5 microunits/mL 87

88. Case Presentation 1 T3 250 ng/dL 80–200 ng/dL Question : How should these results be interpreted? Are confirmatory tests needed? DISCUSSION: This patient presents with many of the clinical features of hyperthyroidism. These include rapid heart rate, weight loss, and heat intolerance. Her thyroid gland is visibly enlarged (goiter). She also has elevated blood pressure and complains of nervousness, sweating, and hand tremors. The diagnosis of hyperthyroidism can be confirmed by her laboratory results of a high T4 and a suppressed TSH value. She has a toxic multinodular goiter that should be treated with radioactive iodine or surgery with antithyroid drug and iodine pretreatment . 88

89. CASE STUDY 2

90. Amy T., a 28-year-old female, visits her physician with complaints of • weakness, • fatigue, •weight gain, •hoarseness, •cold intolerance, and •unusually heavy periods worsening over the past 2 to 3 months . Her HR is 50 beats/min , and her BP is 110/70 mm Hg . Her physical exam is normal , except for a mildly enlarged thyroid gland, pallor, and diminished tendon reflexes . She denies taking any medications or changing her diet .

91. LABORATORY INVESTIGATION Test Result Reference Range Sodium 130 mEq /L 136–142 mEq /L Potassium 3.8 mEq/L 3.8–5 mEq/L Calcium 9.5mg/dL 9.2–11 mg/dL Magnesium 2 mEq /L 1.3–2.1 mEq /L BUN 20 mg/dL 8–23 mg/dL SCr 1.1 mg/dL 0.6–1.2 mg/dL Calcium 9 mg/dL 9.2–11 mg/dL Glucose 80 mg/dL 70–110 mg/dL RBC count 3.5 M/mm3 4–5.2 M/mm3 Cholesterol 235 mg/dL <200 mg/dl Total serum T4 8mcg/dl 5.5-12.5 mcg/dl T3 resin uptake 15% 25-38% Free T4 index 1.2 1–4 Hematocrit 35% 36-45%

92. QUESTION How should these results be interpreted? Are confirmatory tests needed? DISCUSSION: Clinically, all of the history and physical findings point to hypothyroidism. •The pallor and weakness are also consistent with anemia, but an Hct of 35% is unlikely to cause such significant symptoms. • Her cholesterol recently became elevated, consistent with 1° hypothyroidism. •Classically, both the total serum T4 and T3 resin uptake should be low in hypothyroid patients. • In this patient, only the T3 resin uptake is low , and the free T4 index is borderline normal, making laboratory diagnosis unclear. Confirmatory tests should prove useful. A few days later, she revisits her physician for additional tests. When questioned, she admits that she has been taking oral contraceptives and would like to continue. The following day, her TSH is 25 milliunits/L (0.3–5 milliunits/L

93. QUESTION Does this information help to elucidate the diagnosis? DISCUSSION: An elevated TSH confirms primary hypothyroidism . The reason for equivocal total serum T4 and T3 resin uptake is now apparent—the estrogens in the birth control pills. Estrogens elevate total serum T4 and thyroid-binding protein and lower T3 resin uptake . If she had not been taking estrogens, her total serum T4 probably would have been below normal , and her T3 resin uptake probably would have been higher (but still below normal). The diagnosis would have been clear earlier. If oral contraceptive use had been identified at the first visit, a TSH concentration should have been performed then.

94. DISCUSSION She is started on levothyroxine 0.125 mg/day , and her TSH is 6 milliunits/L three weeks later. Clinically, she improves but is not fully back to normal. 6 weeks after starting therapy, she complains of jitteriness, palpitations, and increased sweating . Her TSH is <0.3 milliunit/L . Her physician lowers the dose of levothyroxine to 0.1 mg/day. 8 week later, Her TSH is 1.5 milliunits/L, and she remains asymptomatic . Her cholesterol is 100 mg/dL, sodium is 138 mEq /L, and Hct is 40%

95. QUESTION Which test(s) should be used to determine proper dosing of levothyroxine? How long after a dosage change should clinicians wait before repeating the test(s)? DISCUSSION: •Although total serum T4, T3 resin uptake, and free T4 index can be used to monitor and adjust doses of thyroid supplements in patients with a hypothyroid disorder, the highly sensitive TSH is most reliable . •Chemically, the goal is to achieve a TSH in the normal range , as was ultimately achieved in this patient (TSH of 1.5 milliunits/L). Because of her continued use of birth control pills , TSH is the best test for her. The newer TSH assays make it possible to determine whether TSH secretion is excessively suppressed by thyroid replacement(0.5milliunits/L).With the increased availability of this sensitive test, TSH is becoming the standard for adjusting thyroid replacement therapy in most patients. The 0.125-mg levothyroxine dose is excessive, as evidenced by her “hyperthyroid” symptoms and the fully suppressed TSH. 8 weeks later , after T4 steady-state has been reached on the 0.1-mg/ day dose and after the hypothalamic-pituitary-thyroid axis reached homeostasis, TSH is within the desired range . Her cholesterol, sodium, and Hct is also normalized when she became euthyroid.

96. CASE STUDY 3

97. A 16yr female was admitted to EMR in date 02/13 due to swelling of whole body and later admitted to Female in-patient department. Patient Demography: Patient’s Name: XXXXX Age (yrs.): 16 Weight (kg):XXXX Sex: Female I.P.NO: 247162 Unit: Female Medical Ward DOA: 2081/02/17 DOD: 2081/02/22 Medication History: Stopped Levothyroxine 2 month ago after the permission of the physician. Calcium + vitamin d3, multivitamin, diclofenac gel, febustat 40 mg, gabapentin 100 mg, tizanidine 2mg, pantoprazole, aceclofenac 100 mg. Past medical history : Chronic Thyroiditis with cysts in thyroid gland, muscle stiffness of shoulder, fluid collection in pelvic cavity Social History : Vegeterian Family History: There was no family history of same case or any other disease and disorder. Previous Allergies: No any previous evidences of hypersensitivity of any medication.

98. Objective Evidences physical examinations: General: whole body swelling Pulse: 103bpm spo2:99% Provisional Diagnosis: Or any guess?? P Provisional Diagnosis Any Guess??

99. LABORATORY INVESTIGATION ROUTINE BIOCHEMICAL INVESTIGATION: TESTS RESULT NORMAL RANGE UNITS HAEMATOLOGY: CBC Hemoglobin 9 11-18 Gm/dl PCV 28.9 35-54 % RBC 3.05 4-6.5 Million/ cumm platelet 244000 150-500* 10^3 / Cumm MCV 94.6 76-96 Femtoliter (Fl) MCH 29.7 27-32 Picogram/ cell ( Pg ) MCHC 31.4 30-35 % WBC 4200 4-11 *10^3 / Cumm WBC Differential Neutrophils 62 40-75 % Lymphocytes 30 20-45 % Eosinophils 03 1-4 % Basophil 00 0-1 %

100. Monocyte 05 2-6 % Biochemistry (KFT) B urea 20 20-40 Mg% Serum creatinine 0.7 0.4-1.4 Mg% Na 143 135-155 mmol/L K 4.7 3.5-4.5 mmol/L Bood sugar level RBS 89 70-140 mg/dl LFT Bilirubin total 0.5 0.4-1 Mg% Bilirubin direct 0.2 <0.4 Mg%   Alkaline Phosphate 55 53-128 U/L SGOT 29 5-40 U/L SGPT 25 5-35 U/L Protein 6.8 6-8 Gm% Albumin 3.7 3.4-4.8 Gm%

101. PARASITOLOGY REPORT Total volume 3 8-2.5 Lit Urine protein 0.1    0 to 14 Mg/dl Total 24 hr. urine protein per day 300 <150 mg/day Mg/day ENDOCRINOLOGY REPORT VITAMIN B12 190 211-911 Pg /ml THYROID FUNCTION TEST TSH, ultrasensitive 5280 0.51-4.30 µIU/ml T3, free 2.68 2.56-5.01 Pg /ml T4, free 1.1 0.98-1.63 Ng/ml IRON PROFILE Sr. Iron 70 59-158 Mcg/ml TIBC 299 250-450 Mcg/ml Sr. ferritin 39.8 10-291 Ng/ml

102. From the subjective and objective evidences, it was diagnosed that the patient is having proteinuria with vitamin b12 deficiency . Assessment

103. Patient Specific: To cure the underlying condition of proteinuria and vitamin b12 deficiency Disease specific: ØTo restore the normal function. ØPrevent the further complications of disease. Planning

104. DRUG TREATMENT CHART: DAYS TRADE NAME: GENERIC NAME: R F 1 2 3 4 5 6 7 8 9 10 Inj tramadol 50 mg tramadol 50 mg IV TDS               Tab Fruselac Furosemide + spironolactone (20/50) 1/2 Po OD                Tab vegamin Methyl cobalamin 1500 mg Po OD               Tab folic acid 5 mg Tab folic acid 5 mg PO OD Patient refuse   Tab Loree 1 mg lorazepam PO HS                    Inj. Mega neuron Vitamin b12  IV OD                   Inj Ondansetron 2mg Ondansetron IV SOS                

105. PROGRESS CHART: DAYS: INVESTIGATIONS/OTHERS 02/18 Urine routine examination, SIADH, ANA, vital sign Albumin: nil, sugar: nil, reaction: acidic, Pulse/ resp: 88/20 bpm 02/19 Vital sign B.P: 110/60 mmhg, Temp: 97.6 ° F Epithelial cells: few/ hpf , RBC: nil/ Hpf , Urates: nil, gr. Casts: nil, calcium oxalate: nil, others: nil 02/20 Vital sign B.P: 100/60 mmhg, Temp: 97.6 ° F 02/21 TFT, RFT Nephron consultation and psychiatric consultation. 02/22 serum cortisol was sent for further investigation. B.P: 105/60 mmhg, Temp: 97.6 ° F

106.   Adverse drug event management: Serious hair fall was observed with disturbed sleep. Psychiatric consultation was done and serum cortisol was sent for further investigation. Discharge Medication: Brand name Generic name Strength Frequency Tab meco-od Methyl cobalamin 1500 mg BD* 4 weeks Tab Folvin Folic acid 5 mg OD* 4 weeks

107. DISEASE BASED COUNSELLING:    Education: Patient was provided with detailed information about vitamin b 12 deficiency and proteinuria including causes, risk factors, symptoms, and preventive measures. Lifestyle modifications: Patient was discussed about lifestyle changes that can help prevent deficiency of vitamin b 12 such as balanced diet which include nutrient rich foods such as fruits, vegetables, whole grains, lean proteins and healthy fats and medication adherence. Medication management: Patient was explained about the role of vitamin b12 and folic acid in treating Vitamin b 12 deficiency and proteinuria and the importance of completing the full course of medication as prescribed. Discuss potential side effects, drug interactions, and the importance of avoiding self-medication. Recognizing recurrence: Scheduling follow up appointments with health care providers and monitoring for any signs of complications and to ensure that medication dosage is appropriate and adjusted if needed Emotional support: Patient and care givers were assured that patient would be recovered soon through non-verbal communication skills.

108. DRUG BASED COUNSELLING: Medication regimen: Tab meco- od 1500 mg a) Purpose of the medication: Vitamin b12 is nutritional supplements. It is given to maintain the serum level of vitamin b12 and prevent further vitamin b 12 deficient megaloblastic anemia. b) Dosing instructions: It should with taken orally twice a time with dosing intervals of 12 hours after food. c) Duration of treatment: The complete course is of 4 weeks. d) Side effects: Arthralgia. Dizziness, headache, Nasopharyngitis e) Compliance and missed doses: If a dose is missed, take it as soon as they remember, unless it is close to the time of the next scheduled dose. In that case, they should skip the missed dose and continue with the regular dosing schedule. f) Drug interactions: Warfarin, acetazolamide, amikacin, cimetidine, clonazepam, rabeprazole, aspirin g) Allergic reactions: Anaphylaxis shock, reaction to cobalt

109. Medication regimen: Tab folic acid 5 mg a) Purpose of the medication: Folic acid is nutritional supplements, synthesized vitamin b9. It is given to maintain the serum level of Hemoglobin and prevent further folate deficiency anemia. b) Dosing instructions: It should with taken orally once a day with dosing intervals of 24 hours after food. c) Duration of treatment: The complete course is of 4 weeks. d) Side effects: Bronchospasm, erythema, malaise, pruritis, rash, slight flushing. e) Compliance and missed doses: If a dose is missed, take it as soon as they remember, unless it is close to the time of the next scheduled dose. In that case, they should skip the missed dose and continue with the regular dosing schedule. f) Drug interactions: Green tea (decreases bioavailability of folic acid.) g) Allergic reactions: Hypersensitivity h)  Follow-up:   Follow-up appointment or contact with respected healthcare provider to assess treatment response or monitor for any complications. Serum potassium and platelet counts should be frequently monitored. Hemoglobin level should be assessed one month after each dose adjustments. Serum b12 level should be assessed one month after each dose adjustments.

110. https://www.ndvsu.org/images/StudyMaterials/Biochem/L4-KFTs.pdf https://www.researchgate.net/publication/264933368_Thyroid_function_test_and_its_interpretation https://pro.aace.com/sites/default/files/2020-12/AACE%20TRC%20Interpretation%20of%20TFTs%20Part%203-FINAL.pdf Basic skills on interepreting laboratory data, mary lee, sixth edition https://reference.medscape.com/drug-interactionchecker References:

111. 15 min Reference 111