MHD II, Session VI, Student Copy Page 1 CASE-BASED SMALL GROUP DISCUSSION MHD II SESSION VI Wednesday, MARCH 26, 2014 STUDENT COPY
MHD II, Session VI, 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. Nails are cracking Neuro: no weakness, no paresthesias, 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. 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 H [0.20-5.00] u/ml Free T4 0.1 L [0.8-1.7] ng/dl EDUCATIONAL OBJECTIVES 1. What is the level of thyroid function in this patient? 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?
MHD II, Session VI, Student Copy Page 3 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. Are additional tests needed to confirm the diagnosis? 5. What are the treatment options? What instructions should she be given about taking the prescribed medication? 6. 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. LDL CHOLESTEROL 218 H <100 MG/DL Fin Comment: BASED ON CURRENT GUIDELINES, THIS LEVEL IS VERY HIGH.
MHD II, Session VI, Student Copy Page 4 7. What are some of the cardiac risk factors that are present in this patient? How does that affect therapy? 8. Review Case Images- Endocrinology Set 1
MHD II, Session VI, Student Copy Page 5 CASE 2 History: A 57 year-old woman complains of progressive weight gain of 20 pounds in 1 year, fatigue, postural dizziness, loss of memory, dry skin, constipation, and cold intolerance. Physical examination: Vital signs include a temperature 96.8 o F, pulse 58/minute and regular, BP 110/60. She is moderately obese and speaks slowly. Her voice is deep. She has a puffy face, with pale, cool, dry, and thick skin. The thyroid gland is not palpable. The deep tendon reflex relaxation time is delayed. Laboratory studies TSH 1.0 [0.20-5.00] u/ml Free T4 0.1 L [0.8-1.7] ng/dl EDUCATIONAL OBJECTIVES 1. What is the level of thyroid function in this patient? 2. What are possible etiologies of this patient s condition? 3. What additional aspects of the history and physical examination could provide relevant information to help in the determining the etiology? 4. What additional tests would help confirm the diagnosis? 5. What are the treatment options?
MHD II, Session VI, Student Copy Page 6 CASE 3: History: A 35 year-old woman complained 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 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 and seemed to be staring into the distance. Her skin was warm and moist. There was no focal skin thickening. On ocular exam there was no proptosis, however lid lag was present. 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. On palpation her thyroid gland contained 3 nodules, 2 on the right and one on the left with an estimated total gland size of 60 grams (3 times normal size). All nodules were of firm consistency. There was no cervical or supraclavicular lymphadenopathy. Laboratory studies: TSH <0.1 L [0.20-5.00] u/ml Free T4 2.4 H [0.8-1.7] ng/dl EDUCATIONAL OBJECTIVES 1. What is the patient s level of thyroid function? 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? 3. What are the treatment options? Discuss the mechanism(s) of action and side-effects of pharmacologic treatments. 4. What is lid lag and how is it elicited?
MHD II, Session VI, Student Copy Page 7 5 Comment on the patient s menstrual periods. Is there a relationship to her thyroid disease? 6. What, if any, is the significance of the patient s murmur? 7. Review Case Images. Endocrinology Set 2
MHD II, Session VI, Student Copy Page 8 Case 4: 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 L [0.20-5.00] u/ml Free T4 2.4 H [0.8-1.7] ng/dl EDUCATIONAL OBJECTIVES 1. What is the level of thyroid function in this patient? 2. What is the most likely etiology of this patient s condition? What test(s) are useful to confirm its cause? 3. What are the treatment options? 4. Review Case Images Endocrinology Set 3
MHD II, Session VI, Student Copy Page 9 Case 5: 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. Menstrual periods had been regular but there was less bleeding. She has lost 20 pounds over 4 months and feels that this has helped her relationship with her husband. Physical examination: Pulse was 102/minute and BP was 130/60. She appeared anxious and seemed to be staring into the distance. Her skin was warm and moist; however there was no focal skin thickening. On ocular exam there was no proptosis, however lid lag was present. 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. Her thyroid was not palpable and there was no lymphadenopathy. Laboratory studies: TSH <0.1 L [0.20-5.00] u/ml Free T4 2.4 H [0.8-1.7] ng/dl EDUCATIONAL OBJECTIVES 1. What is the level of thyroid function in this patient? 2. Develop a differential for the etiology of this patient's illness. THYROID IMAGING WITH UPTAKE 400 uci 123-I SODIUM IODIDE PO CPT: 780064 HISTORY: HYPERTHYROID PINHOLE IMAGES OF THE THYROID OBTAINED IN MULTIPLE PROJECTIONS ARE NORMAL. THE 24 HOUR IODINE UPTAKE IS CALCULATED IS LESS THAN 1%. THIS IS WELL BELOW THE NORMAL RANGE OF 7-30%. *** IMPRESSION: NORMAL THYROID SCAN. MARKEDLY DECREASED THYROID UPTAKE. *** **
MHD II, Session VI, Student Copy Page 10 3. Does the result of the scan narrow the differential? At a follow-up visit, the patient is tearful. She has lost her job as a pharmacy technician and is fearful that she will gain weight because she will no longer have her diet pills. 4. What do you suspect is the diagnosis? 5. Review Case Images. Endocrinology Set 4 Case 6 Unknown Students will not have case until the session meets.