CASE-BASED SMALL GROUP DISCUSSION

Transcription

1 MHD II, Session 7, Faculty Copy - Page 1 CASE-BASED SMALL GROUP DISCUSSION MHD II Session 7 March 23, 2016 Student Copy

2 MHD II, Session 7, Faculty Copy - Page 2 Case 1 CC: I have had irregular periods and have not been able to have a baby despite trying for 4 years History of Present Illness A 32-year-old woman presented for evaluation of oligomenorrhea and difficulty becoming pregnant. Menarche had occurred at 11 years of age and menses were regular until the patient was 28 years old at which time irregular cycles developed, ranging from 31 to 51 days, with menstrual flow of 7 days' duration. She had no pain with menstruation and no intermenstrual bleeding. She reported that Papanicolaou smears had been normal. There was no history of sexually transmitted diseases or use of intrauterine devices. Between the ages of 28 and 32 years, she had unprotected coitus with her husband but did not conceive. The patient reported that testing with over-the-counter ovulation-predictor kits did not show evidence of ovulation. The patient explains that one of her friends has PCOS and she wonders if that is what she has as well. Past Medical History No known chronic medical problems No surgeries Medications: prenatal vitamins and folate Allergies: NKDA Social History: Never smoked, never used illicit drugs, drinks alcohol rarely Married Works in IT in an academic setting Family History. Mother with high cholesterol and osteoporosis Father obese, with peripheral edema and prostatic hypertrophy Maternal aunt with diabetes mellitus type 2 Review of Systems Positives: Dermatologic: She reported frequent acne and facial hair that she removed manually HEENT: Chronic sinus headaches Physical exam: BP 110/68, pulse 72, respirations 12, afebrile, BMI 26. Examination, including pelvic examination revealed no abnormalities. Ultrasonography of the pelvis revealed that the endometrium was 8.8 mm thick and homogeneously echogenic; 3 simple cysts were present in the right ovary; 2 simple cysts were present in the left ovary.

3 MHD II, Session 7, Faculty Copy - Page 3 Educational Objectives 1. Define oligmenorrha. Define infertility 2. Develop a broad differential diagnosis for the etiology of oligomenorrhea in this patient. 3. What factors that support the diagnosis of polycystic ovarian syndrome in this patient? What data suggests that she does not have polycystic ovarian syndrome? 4. Label the pituitary and ovarian hormones (A-D) through the menstrual cycle.

4 MHD II, Session 7, Faculty Copy - Page 4 5. What do over the counter urine ovulation kits measure? If a patient has PCOS, how would it affect the results of the test? After comprehensive infertility evaluation, clomiphene citrate was administered on days 5 through 9 of her cycle. 6. What is the mechanism of action of clomiphene?

5 MHD II, Session 7, Faculty Copy - Page 5 Lab Data 3 rd day of menstrual cycle 10 th day of menstrual cycle (after clomiphene days 5-9) 3oth day menstrual cycle Estradiol <32 <32 FSH Progesterone 1.3 LH 2.6 Reference values Estradiol (pg/ml) Follicular phase Mid-cycle Luteal phase Follicle stimulating hormone (miu/ml) Follicular phase Mid cycle Luteal phase Progesterone (ng/ml) Follicular phase Mid cycle Luteal phase Luteinizing hormone (miu/ml) Follicular phase Mid cycle Luteal phase Interpret the laboratory data.

6 MHD II, Session 7, Faculty Copy - Page 6 With ongoing fertility treatment, the patient ultimately became pregnant. The pregnancy was complicated by gestational diabetes mellitus, which was diet-controlled. After a 39-week gestation, the patient delivered a healthy infant via spontaneous vaginal delivery. She breast-fed her child for 12 months and had one spontaneous episode of menstrual flow during that time. Glucose intolerance persisted, but she declined treatment. 8. What information provided suggests adequate prolactin production? For the next 2 years, the patient developed persistent frontal headaches and nasal discharge. She had intermittent episodes of acute sinusitis, treated with antibiotics and nasal spray, and seasonal environmental allergies. On further discussion, the patient reported decreased libido, intermittent hot flashes accompanied by palpitations, and amenorrhea for almost 1 year. She had occasional floaters in her vision. She experienced chronic pain and stiffness in the knees, shoulders, and hands, as well as occasional numbness and tingling in the hands, which had been occurring for approximately 5 years. During the same period, increasing numbers of coarse dark hairs grew on her face. Her weight had increased by~36 pounds. Snoring, fatigue, and occasional daytime somnolence, developed. Her shoe size had increased from size 7 medium to size 7.5 wide, her ring size had also increased, and she thought that her nose had become larger. She did not have abdominal pain, nausea, vomiting, diarrhea, dizziness, chest pain, respiratory symptoms, peripheral edema, or excessive thirst or hunger or polyuria. Medications included vitamins, calcium, n 3 fish oil, topical tretinoin, benzoyl peroxide, and loratadine as needed. On physical exam vital signs were normal. Body mass index was The face and nose were broad, the brow was prominent, and the teeth and jaw revealed a slight underbite; there was no macroglossia. There was facial acne, multiple skin tags, and acanthosis nigricans. The hands were large, and the fingers were thick. The remainder of the examination was normal. The remainder of the questions 8-11 will be provided during the small group session.

7 MHD II, Session 7, Faculty Copy - Page 7 Case 2 Cc: I have been urinating way too much for too long The patient is an 18 year-old male who noted the onset of severe headache and markedly increased urination about 18 months prior to admission. He stated that the onset of the increased urination had been dramatic and abrupt and he could recall the exact day it had begun. He said that he would urinate times during the waking hours and would have to get up 5-6 times per night for further urination. He said he had an intense thirst with the craving for ice cold beverages and consequently during the last few months had been consuming vast quantities of water, but he seemed quite sure that the increase in urinary frequency preceded the increase in drinking. As an outpatient he, on the advice of his doctor, made a 24-hour urine collection and the volume of that collection was 5 liters. He further stated that he never developed body or facial hair and had never shaved. He felt embarrassed that while the voices of many of his friends were deepening, he was still a soprano. Although he tried to involve himself in vigorous body building activity, he felt that his muscular development was lacking. He also lacked libido and had been unable to have an erection for about one year. He said that he had been growing until the age of 14 years when his growth simply ceased. Over the time course of all these symptoms, he felt generally tired and depressed. PAST MEDICAL HISTORY Although the patient has been generally healthy prior to the onset of the current symptoms, it is notable that 6 months ago he was involved in an automobile accident. His car was hit in the rear when he was switching from the center to the left lane and did not see the car coming up beside him. He did not sustain head trauma. PHYSICAL EXAMINATION The patient was alert and oriented to person, time and place. Pulse - 56/min; blood pressure - 110/70 mmhg; respiratory rate 16/min; temperature - 96 F; height - 65 inches; weight pounds. HEENT Neck Chest Lungs Heart Abdomen Genitalia Extremities Skin Neurologic Hair Examination was unremarkable, except that on gross confrontation his temporal visual fields were constricted bilaterally. Thyroid not palpable. Bilateral white liquid was expressed with firm squeezing from his nipples. Clear S1 and S2 were normal. There was no S3, S4 or murmurs. Unremarkable The penis was small, measuring about 4-6 cm in length. The scrotal sack lacked rogation, pigmentation or a median raphe. The testes were soft and small, measuring about 1.5 cm in longest diameter. Within normal limits Cool, dry, pale. The neurologic examination was normal, except for generalized muscle weakness and hung-up deep tendon reflexes. Very little hair was found on the face or in the axillary or pubic areas.

8 MHD II, Session 7, Faculty Copy - Page 8 1. Develop a problem list. EDUCATIONAL OBJECTIVES CASE 3 2. With respect to the patient s presenting concern of urinating too much - define polyuria. What are the 2 potential mechanisms? How would the urine osmolality help distinguish the two? The physician formulates a differential diagnosis and orders the following: Glucose 100 mg/dl (nl ) Sodium 145 mmol/l (nl ) Potassium 4 mmol/l (nl ) Chloride 100 mmol/l (nl ) CO2 24 mmol/l (nl 20-32) Calcium 9.4 mg/dl (nl ) BUN 30 mg/dl (nl 7-22) Creatinine 0.9 mg/dl (nl ) UA w/micro Color PALE [YELLOW] YELLOW Clarity CLEAR [CLEAR] ph 5.0 [ ] Spec Gravity [ ] Protein NEG [NEG] Blood NEG [NEG] Glucose NEG [NEG] Ketones NEG [NEG] Bilirubin NEG [NEG] Urobilinogen 0.2 [ ] eu/dl NITRATE NEG [NEG] LEUKOCYTES NEG [NEG] RBC 0-2 [0-2] /hpf WBC 0 [0-5] /hp

9 3. Interepret the laboratory data MHD II, Session 7, Faculty Copy - Page 9 WATER DEPRIVATION TEST Time Weight B.P. Pulse Urine Osm. Plasma Osm. Urine (hrs) (lbs) (mmhg) (bts/min) (mosm/kg) (mosm/kg) Output / / / / (5 U AVP) / / / Serum AVP (arginine vasopressin) unmeasurable just before exogenous AVP was given. 4. Explain the results of the water deprivation test. What is the cause of this patient s polyuria? MRI of the brain is done and shows a large focally calcified mass with supra-sella extension. Additional data and questions 5-9 will be provided during the small group session. Case 3 Unknown Case data will be provided during the session