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CASE 1

A 48-year-old male presents to the clinic because of concerns about heart disease. He reports

that his father died from a heart attack at age 46, and his older brother has also had a heart

attack at age 46 but survived and is on medications for elevated cholesterol. The patient

reports chest pain occasionally ith ambulation around his house and is not able to climb

stairs ithout significant chest pain and shortness of breath. The physical e!am is normal,

and the physician orders an electrocardiogram "#$%&, e!ercise stress test, and blood ork.

The patient's cholesterol result comes back as ()* mg+d "normal **&. The physician

prescribes medication, hich he states is directed at the ratelimiting step of cholesterol

biosynthesis.

What is the rate-limiting step of cholesterol metabolism?

What is the class of medication prescribed?

CASE 2 ()Lofata Brne is a 6-year-old girl. /ince age 4 months she has e!perienced recurrent

episodes of profound fatigue associated ith vomiting and increased perspiration, hich

re0uired hospitali1ation. These episodes occurred only if she fasted for more than 8 hours.

2ecause her mother gave her food late at night and oke her early in the morning for

breakfast, ofata's physical and mental development had progressed normally.3n the day of

admission for this episode, ofata had missed breakfast, and by noon she as e!tremely

fatigued, nauseated, seaty, and limp. /he as unable to hold any food in her stomach and

as rushed to the hospital, here an infusion of glucose as started intravenously. Her

symptoms responded dramatically to this therapy.

Her initial serum glucose level as lo at (8 mg+d "reference range for fasting serum

glucose levels 5***&. Her blood urea nitrogen "27& level as slightly elevated at 6

mg+d "reference range 8)& as a result of vomiting, hich led to a degree of dehydration.

Her blood levels of liver transaminases ere slightly elevated, although her liver as not

palpably enlarged. 9espite elevated levels of free fatty acids "4.( m:& in the blood, blood

ketone bodies ere belo normal. What happened !ith Lofata Brne?

CASE "

A 6(-year-old female presents to the clinic ith recurrent midepigastric pain over the last (

months. /he reports some relief shortly after eating, but then the discomfort returns. /he has

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tried various over-the-counter medications ithout relief. /he also reports feeling tired and

has had to increase the amount of ibuprofen needed for relief of her arthritis. /he denies

nausea, vomiting, and diarrhea. 3n e!am she is found to have mild midepigastric tenderness

and guaiac positive stool. A $2$ revealed a microcytic anemia and normal hite blood cell

count, consistent ith iron deficiency. The patient as referred to a gastroenterologist ho

performed an upper %; endoscopy that identified gastric ulcers. He stated that he suspected

that the ibuprofen, a nonsteroidal antiinflammatory drug "/A;9& as the causative agent

and suggested sitching from ibuprofen to a co!ib, such as celeco!ib.

What is the li#el$ biochemical etiolog$ of the disorder?

Wh$ do co%ibs generall$ ha&e a lo!er incidence of pper ' problems than other

SA*s?

What is the ma+or difference bet!een aspirin and other SA*s !ith regard to

platelet fnction?

CASE , ()*iana, a 5-year-old oman ith type diabetes mellitus, had been admitted to the hospital

in a ketoacidotic coma a year ago. /he had been feeling drosy and had been vomiting for 4

hours before that admission. At the time of admission, she as clinically dehydrated, her

blood pressure as lo, and her breathing as deep and rapid "

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CASE / ()Emma Whee0er has done ell ith regard to her respiratory function since her earlier

hospitali1ation for an acute asthmatic attack. /he has been maintained on to puffs oftriamcinolone acetonide, a potent inhaled corticosteroid, three times per day, and has not

re0uired systemic steroids for months. The glucose intolerance precipitated by high

intravenous and oral doses of the synthetic glucocorticoid de!amethasone during her earlier

hospitali1ation resolved after this drug as discontinued. /he has come to her doctor no

because she is concerned that the lo-grade fever and cough she has developed over the last

(6 hours may trigger another acute asthma attack.What happened !ith Emma Whee0er?