MHD II, Session X, STUDENT Copy Page 1 ENDOCRINOLOGY CASE-BASED SMALL GROUP DISCUSSION SESSION X MHD II April 2, 2015 STUDENT COPY
MHD II, Session X, STUDENT Copy Page 2 CASE 1 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. Her menstrual periods have changed they have been occurring about every 40 days instead of every month. 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 CASE 3 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.
MHD II, Session X, STUDENT Copy Page 3 4. What is lid lag and how is it elicited? 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 X, STUDENT Copy Page 4 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 L [0.20-5.00] u/ml Free T4 2.4 H [0.8-1.7] ng/dl EDUCATIONAL OBJECTIVES CASE 4 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 X, STUDENT Copy Page 5 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 [0.7-1.4] mg/dl Calcium 11.5 H [8.5-10.5] mg/dl Sodium 140 [136-146] mmol/l Potassium 4.1 [3.5-5.3] 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?
MHD II, Session X, STUDENT Copy Page 6 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 10-65 8.5-10.5 PRIMARY HYPERPARATHYROIDISM >60 >10.5 HYPERCALCEMIA OF MALIGNANCY <20 >10.5 HYPOPARATHYROIDISM <10 <8.5 * * * * * TSH 2.25 [0.20-5.00] uu/ml Phosphorous 2.3 L [2.6-4.4] mg/dl Urine Calcium 8.6 H [1.5 4.5] mg/kg Collection start 0800 on 12-17-09 Collection end 0800 on 12-18-09 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?
MHD II, Session X, STUDENT Copy Page 7 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
MHD II, Session X, STUDENT Copy Page 8 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 [136-146] mm/l Potassium 3.9 [3.3-5.1] 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 [0.7-1.4] mg/dl Glucose 118 [70-100] mg/dl Albumin 2.0 L [3.6-5.0] gm/dl Protein, Total 5.2 L [6.5-8.3] gm/dl Calcium 14.9 H [8.9-10.3] 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 [0.2-1.4] mg/dl Magnesium 1.4 L [1.7-2.8] mg/dl Phosphorous 5.2 H [2.6-4.4] mg/dl
MHD II, Session X, STUDENT Copy Page 9 CBC WBC 10.1 H [4.0-10.0] k/ul RBC 2.59 L [3.60-5.50] m/ul Hgb 10.2 L [12.0-16.0] gm/dl Hct 30.6 L [34.0-51.0] % MCV 83.2 L [85-95] fl MCH 27.4 [28.0-32.0] pg MCHC 32.3 [32.0-36.0] gm/dl RDW 15.1 H [11.0-15.0] % Plt Count 151 [150-400] 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 10-65 8.5-10.5 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?
MHD II, Session X, STUDENT Copy Page 10 TABLE 1. Day 0 1 2 3 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) 16.5 15.4 12.3 10.9 Creatinine (mg/dl) 2.6 2.2 1.8 1.9 Intake, ml 6000 9,700 6000 4000 Output, ml 7200 6,200 5500 4000 2. Discuss the principles of treatment of the patient s hypercalcemia as outlined in Table 1. 3. 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)
MHD II, Session X, STUDENT Copy Page 11 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.
MHD II, Session X, STUDENT Copy Page 12 Additional diagnostic studies BONE DENSITY/DUAL PHOTON NO ISOTOPE ADMINISTERED CPT: 76075-1 THE AVERAGE DEXA BMD OF THE L2-L4 LEVEL IS 0.943 GM/CM2 WITH A T SCORE OF -3.2. THIS VALUE IS IN THE OSTEOPOROSIS RANGE. THE DEXA BONE MINERAL DENSITY (BMD) OF THE LEFT FEMORAL NECK IS 0.651 GM/CM2 WITH A T SCORE OF -2.4. 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 [0.20-5.00] u/ml Calcium 9.1 [8.9-10.3] mg/dl Phosphorous 3.1 [2.6-4.4] mg/dl Vitamin D, 25-Hydroxy 42 ng/ml REFERENCE RANGE: 30-80 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: 20-29 ng/ml Optimum Level: 30-80 ng/ml Possible Toxicity: Greater than 80 ng/ml Educational Objectives: 1. What is the most likely etiology of the vertebral compression fracture? List some of the major risk factors for the development of this condition in this patient.
MHD II, Session X, STUDENT Copy Page 13 2. What change(s) in medication should be made after results of the TSH are available? 3. Define T Score as reported in the bone mineral density scan. 4. Could this patient have osteomalacia? 5. Recommend lifestyle changes to treat the patient s bone disease. 6. Discuss the recommended dietary allowance (RDA) of calcium and vitamin D for this patient. How can she achieve her requirements?
MHD II, Session X, STUDENT Copy Page 14 7. Discuss the first line pharmacologic therapy for treatment of this patient s bone disease. What is the mechanism of action? Cite 2 routes of administration. What are main side/adverse effects The patient does her best to adhere to the treatment plan. Two years later her bone mineral is increased by 6%. density 8. Review the Case Images-Musculoskeletal Set 2 Case 6 Unknown - Students will not have case data until session meets