MHD II, Session 9, STUDENT Copy Page 1 ENDOCRINOLOGY CASE-BASED SMALL GROUP DISCUSSION SESSION 9 MHD II. March 29, 2017 STUDENT COPY

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1 MHD II, Session 9, STUDENT Copy Page 1 ENDOCRINOLOGY CASE-BASED SMALL GROUP DISCUSSION SESSION 9 MHD II March 29, 2017 STUDENT COPY

2 MHD II, Session 9, STUDENT Copy Page 2 CASE 1 History: A 57-year-old woman presents to a physician with the chief concern of progressive weight gain of 20 pounds in 1 year. Her appetite has been about the same but she has become less active because of constant fatigue. She has no known chronic medical problems. She takes a multivitamin daily, calcium citrate/vitamin D3 315mg/200 IU 2 tabs daily, and acetaminophen as needed for various aches and pains. About six months ago she began taking a laxative for constipation. Review of systems: General: no fevers, feels cold all the time Pulmonary: mild dyspnea on exertion ever since I gained all this weight, no cough Cardiovascular: no chest pain, no paroxysmal nocturnal dyspnea, no orthopnea, occasional ankle swelling Skin: using more lotions for dry skin. Neuro: no weakness, no parasthesias, kids commented recently that she seems more spacey and forgetful Endo: no polyuria or polydipsia Physical examination: Vital signs: temperature 96.8 o F, pulse 58/minute and regular, BP 140/100. She is moderately obese and speaks slowly. Her face appears puffy with pale, cool, dry, and thick skin. There is mild peri-orbital edema. The thyroid gland is slightly enlarged, firm, not nodular, mobile, and not tender. There is no cervical lymphadenopathy. Lungs are clear to auscultation and percussion. On heart exam S1 and S2 are normal and there are no extra heart sounds. The abdomen is protuberant; there is no organomegaly. The deep tendon reflex relaxation time is delayed. The physician formulates a differential diagnosis and orders the following: Laboratory studies: TSH 23.0 [ ] u/ml Free T4 0.1 [ ] ng/dl EDUCATIONAL OBJECTIVES 1. What is the level of thyroid function in this patient? Correlate with the clinical findings.

3 MHD II, Session 9, STUDENT Copy Page 3 2. Radioimmunoassays are widely available for measurement of serum total T4 (as well as total T3). Why did this physician order the unbound, or free, T4 level? 3. What are the most common causes of this patient s condition? What additional aspects of the history and physical examination could provide relevant information to help determine the etiology? 4. What are the treatment options? What instructions should she be given about taking the prescribed medication? 5. The patient s physician orders a lipid profile. Why? Component Results Component Value Flag Low High Units Stat CHOLESTEROL 271 H <200 MG/DL Fin Comment: BASED ON CURRENT GUIDELINES, THIS LEVEL IS HIGH. * * * * COMPLETE NCEP RANGES, RISK LEVELS AND TREATMENT INFORMATION IS AVAILABLE AS A PRACTICE GUIDELINE IN THE PHYSICIAN ORDER ENTRY AND CLINICAL PROTOCOLS SECTION OF LUMC'S ELECTRONIC MEDICAL RECORD. TRIGLYCERIDE 225 <150 MG/DL Fin Comment: TRIGLYCERIDE REFERENCE RANGE APPLIES TO FASTING SAMPLE * * * * BASED ON CURRENT GUIDLELINES, THIS LEVEL IS HIGH. HDL CHOLESTEROL 34 L >39 MG/DL Fin Comment: BASED ON CURRENT GUIDELINES, THIS LEVEL INDICATES HIGHER RISK.

4 MHD II, Session 9, STUDENT Copy Page 4 LDL CHOLESTEROL 218 H <100 MG/DL Fin Comment: BASED ON CURRENT GUIDELINES, THIS LEVEL IS VERY HIGH. 6. What are the cardiac risk factors that are present in this patient? How does that affect therapy? 7. Review Case Image - Endocrinology Set 1.

5 MHD II, Session 9, STUDENT Copy Page 5 Case 2: History: A 35 year-old woman complained of nervousness, mood swings, 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 had maintained a normal weight of 120 pounds but was eating twice as much as she did 1 year ago. Menstrual periods have been regular but there was less bleeding. Physical examination: Pulse was 102/minute and BP was 130/60. She appeared anxious. Her skin was warm and moist. There was scaly thickening and induration of the pretibial skin. Her eyes appeared proptotic and there was mild periorbital edema. She had a fine tremor. On cardiovascular exam there was a bounding cardiac apical impulse and a soft, early to mid-systolic murmur at the left upper sternal border (between 2nd and 3rd ribs). She could not rise from a deep knee bend without aid. The thyroid gland was diffusely enlarged without palpable nodules. Laboratory studies TSH <0.1 [ ] u/ml Free T4 2.4 [ ] ng/dl EDUCATIONAL OBJECTIVES CASE 4 1. What is the level of thyroid function in this patient? 2. What are possible etiologies of this patient s condition? What is the most likely etiology? What test(s) are useful to confirm its cause?

6 MHD II, Session 9, STUDENT Copy Page 6 3. What are the treatment options? 4. Review Case Images Endocrinology Set 3

7 MHD II, Session 9, STUDENT Copy Page 7 Case 3 Cc: I was recently informed that my calcium level is high A 44 year-old woman commercial airline pilot was applying for additional disability insurance. The insurance company had her consent for a set of routine screening blood tests. In a follow-up letter to the patient it was stated that all of tests were normal aside from a high calcium level. The patient follows up with her primary care physician. Aside from feeling tired, she has no complaints. She has no medical problems. She has had blood tests before and has never been told of any abnormalities. Six years prior she had undergone total abdominal hysterectomy secondary to uterine fibroids. She takes no medications regularly. She does not smoke and drinks a glass of wine with dinner when not working. She is married and has 2 healthy children. She is unaware of any family history of hypercalcemia or other endocrinopathy. On physical exam the patient appears healthy. BP 122/64; P 68, R 14. There is no cervical lymphadenopathy or palpable nodules. The thyroid gland is normal in size. Lung, heart, and abdominal exams are normal aside from a well-healed lower abdominal transverse surgical scar. Neurologic exam is normal. Laboratory Data Basic Metabolic Panel Glucose 88 [70-100] mg/dl Blood Urea Nitrogen 8 [7-22] mg/dl Creatinine 0.8 [ ] mg/dl Calcium 11.5 H [ ] mg/dl Sodium 140 [ ] mmol/l Potassium 4.1 [ ] mmol/l Chloride 104 [98-108] mmol/l Carbon Dioxide 26 [20-32] mmol/l EDUCATIONAL OBJECTIVES 1. Develop a differential diagnosis of hypercalcemia for this patient. 2. What symptoms may develop as a result of hypercalcemia?

8 MHD II, Session 9, STUDENT Copy Page 8 Additional Laboratory Data INTACT PTH 184 pg/ml REFERENCE VALUES FOR THE INTERPRETATION OF ipth IN CONJUNCTION WITH THE TOTAL SERUM CALCIUM CONCENTRATION IN ADULTS ARE AS FOLLOWS: * * * * * -- INTERPRETATION-- ipth TOTAL CALCIUM (PG/ML) (MG/DL) NORMAL PRIMARY HYPERPARATHYROIDISM >60 >10.5 HYPERCALCEMIA OF MALIGNANCY <20 >10.5 HYPOPARATHYROIDISM <10 <8.5 * * * * * TSH 2.25 [ ] uu/ml Phosphorous 2.3 L [ ] mg/dl Urine Calcium 8.6 H [ ] mg/kg Collection start 0800 on Collection end 0800 on A recent mammogram was normal. 3. What is the likely diagnosis? 4. What is benign familial hypercalcemia? What features exclude benign familial hypercalcemia in this case?

9 MHD II, Session 9, STUDENT Copy Page 9 Ultrasonographic exam of the neck showed a well-circumscribed, rounded, homogeneous, hypoechoic mass measuring 2.0 x 4.0 cm inferior and lateral to the inferior aspect of the right lobe of the thyroid gland. 5. What would you anticipate as findings during surgical exploration of the patient s neck? 6. Review the Case Images Endocrinology Set 6

10 MHD II, Session 9, STUDENT Copy Page 10 CASE 4 Cc: I am having a very hard time waking my wife up this morning. She s been doing poorly for the past several days. The patient is a 67 year old woman with widely metastatic breast cancer (metastases to liver, lungs, spine) who is brought to the emergency department minimally responsive. Her husband reports that over the preceding 5-6 days she has seemed more confused. She has had a poor appetite and complained of occasional abdominal pain and nausea. Today she was in bed longer than usual and her husband had difficulty waking her up. He was concerned and called 911. Finger stick glucose done by the paramedics was 120mg/dl. Medications: docusate 100mg twice a day senna 1 tablet at bedtime oxycodone extended release 30mg every 12 hours oxycodone 5mg every three hours as needed for breakthrough pain naproxen 500mg twice daily multivitamin daily On physical exam the patient is arousable only with noxious stimuli. T-99.9, P- 92, R 14, BP 102/66, oxygen saturation on room air 94%. She appears cachectic. Skin turgor is poor. Mucous membranes are dry. The jugular venous pulse does not fill with the patient supine. There is a right chest wall scar from previous mastectomy. Heart exam demonstrates normal S1 and S2 without S3, S4 or murmurs. There are decreased breath sounds at both lung bases, otherwise the lungs are clear to auscultation. Abdomen is flat; the liver is enlarged and firm; there is no splenomegaly. There is no peripheral edema. Laboratory Data COMPLETE METABOLIC PANL Sodium 139 [ ] mm/l Potassium 3.9 [ ] mm/l Chloride 102 [98-108] mm/l CO2 26 [20-32] mm/l Bun 53 H [7-22] mg/dl Creatinine 2.6 H [ ] mg/dl Glucose 118 [70-100] mg/dl Albumin 2.0 L [ ] gm/dl Protein, Total 5.2 L [ ] gm/dl Calcium 14.9 H [ ] mg/dl Alkaline Phosphatase 192 H [30-110] iu/l ALT (SGPT) 47 H [7-35] iu/l AST (SGOT) 57 H [5-40] iu/l Bilirubin, Total 2.0 H [ ] mg/dl Magnesium 1.4 L [ ] mg/dl Phosphorous 5.2 H [ ] mg/dl

11 MHD II, Session 9, STUDENT Copy Page 11 CBC WBC 10.1 H [ ] k/ul RBC 2.59 L [ ] m/ul Hgb 10.2 L [ ] gm/dl Hct 30.6 L [ ] % MCV 83.2 L [85-95] fl MCH 27.4 [ ] pg MCHC 32.3 [ ] gm/dl RDW 15.1 H [ ] % Plt Count 151 [ ] k/ul INTACT PTH 2 pg/ml REFERENCE VALUES FOR THE INTERPRETATION OF ipth IN CONJUNCTION WITH THE TOTAL SERUM CALCIUM CONCENTRATION IN ADULTS ARE AS FOLLOWS: * * * * * -- INTERPRETATION-- ipth TOTAL CALCIUM (PG/ML) (MG/DL) NORMAL PRIMARY HYPERPARATHYROIDISM >60 >10.5 HYPERCALCEMIA OF MALIGNANCY <20 >10.5 HYPOPARATHYROIDISM <10 <8.5 * * * * * Educational Objectives 1. Based on the given information, what is the most likely etiology of hypercalcemia in this patient? What are the mechanisms of hypercalcemia?

12 MHD II, Session 9, STUDENT Copy Page 12 TABLE 1. Day Clinical Status -Minimally responsive -Minimally responsive -Arousable - Crackles on lung exam, jugular -Talking Medications -NaCl IV Infusion -Calcitonin 4units/kg SQ every 8 hours -Pamidronate IV 60mg over 4 hours -NaCl IV -Calcitonin SQ venous distention -NaCl IV -Furosemide 40mg IV Calcium (mg/dl) Creatinine (mg/dl) Intake, ml , Output, ml , Discuss the principles of treatment of the patient s hypercalcemia as outlined in Table Why was calcitonin used only for the first 48 hours of hospitalization? 4. What EKG finding is associated with hypercalcemia? (see small group case images Endocriology set 7)

13 MHD II, Session 9, STUDENT Copy Page 13 CASE 5: Cc: My back has been killing me since last night A 52 year-old Caucasian woman presents to clinic with complaints of an acute onset of upper back pain. She is accompanied by her best friend. The pain began with her rolling over in bed the night before. The pain is unrelenting, 6-7/10. She could barely get dressed on account of the pain. She has no other complains. Her past medical history is significant for thyrotoxicosis between the ages of 20 and 26; it was treated with radioiodine; she has been maintained on levothyroxine 200mcg daily. She takes no other medications. She smokes 1 pack of cigarettes per day and has done so for 40 years. She does not drink alcohol. Menopause occurred at age 49. Her father died of a myocardial infarction at the age of 54. Her mother died recently and had osteoporosis and dementia. She has one younger sister who has diabetes mellitus. On physical exam the patient is 68 inches tall (she believes that she was 70 inches tall several years ago), weighs 118 pounds, has a blood pressure of 120/80 mm Hg and a regular pulse of 94 per minute. There was dorsal kyphosis and tenderness to palpation at T8. The thyroid was not palpable. Neurologic examination was normal. Diagnostic Studies EXAM: DXSPTHOR2 - THORACIC SPINE, 2 VIEWS THORACIC SPINE AND LUMBAR SPINE: THERE IS COMPRESSION FRACTURE OF T8 VERTEBRAL BODY AND MINIMAL COMPRESSION OF T10. NO COMPRESSION DEFORMITY SEEN IN THE LUMBAR VERTEBRAE. THERE IS GENERAL DEMINERALIZATION OF THE THORACOLUMBAR SPINE. OSTEOPHYTE FORMATION SEEN IN THE DORSAL SPINE, AND ALSO AT L3/4. Non-steroidal anti-inflammatory agents were recommended for pain. The patient was asked to mobilize as pain allowed and to follow-up with her physician in 1 week.

14 MHD II, Session 9, STUDENT Copy Page 14 Additional diagnostic studies BONE DENSITY/DUAL PHOTON NO ISOTOPE ADMINISTERED CPT: THE AVERAGE DEXA BMD OF THE L2-L4 LEVEL IS GM/CM2 WITH A T SCORE OF THIS VALUE IS IN THE OSTEOPOROSIS RANGE. THE DEXA BONE MINERAL DENSITY (BMD) OF THE LEFT FEMORAL NECK IS GM/CM2 WITH A T SCORE OF THIS IS IN THE OSTEOPENIC RANGE. ACCORDING TO THE WORLD HEALTH ORGANIZATION CRITERIA FOR OSTEOPOROSIS: INCREASED BMD: T SCORE > +1.0 NORMAL BMD: T SCORE = +1.0 TO -1.0 OSTEOPENIA: T SCORE = -1.0 TO -2.5 OSTEOPOROSIS: T SCORE < -2.5 *** IMPRESSION: DECREASED BMD OF THE LUMBAR SPINE CONSISTENT WITH OSTEOPOROSIS AND LEFT FEMORAL NECK CONSISTENT WITH OSTEOPENIA. *** TSH <0.1 [ ] u/ml Calcium 9.1 [ ] mg/dl Phosphorous 3.1 [ ] mg/dl Vitamin D, 25-Hydroxy 42 ng/ml REFERENCE RANGE: NG/ML TEST INFORMATION: VITAMIN D, 25-HYDROXY This assay quantifies the sum of vitamin D3, 25-hydroxy and vitamin D2, 25-hydroxy. Deficiency: Less than 20 ng/ml Insufficiency: ng/ml Optimum Level: ng/ml Possible Toxicity: Greater than 80 ng/ml Educational Objectives: Students will be provided questions during the small group session. Be prepared to prepared to answer questions regarding the most likely diagnosis, pathogenesis, diagnostic testing and therapy.