Targeted Issues in Endocrinology Joshua S. Coren, DO, MBA, FACOFP

Targeted Issues in Endocrinology Joshua S. Coren, DO, MBA, FACOFP

Endocrine in 25 Minutes Joshua S. Coren, D.O., MBA, FACOFP Vice Chair and Associate Professor, Family Medicine Rowan University School of Osteopathic Medicine Outline Goals Pituitary Thyroid Parathyroid Other Endocrine 1

ANTERIOR PITUITARY Follicle-stimulating hormone Luteinizing Hormone Adrenocoricotropic Hormone Thyroid-Stimulating Hormone Prolactin Beta-Endorphins Growth Hormone POSTERIOR PITUITARY Oxytocin Vasopressin Case 1 32 y.o. female evaluated for Amenorrhea - LMP = 4 Months Ago - Home Pregnancy Tests Negative x 2 - Menarche at Age 11 - Regular Cycle until 4 Months Ago - Weekly Headaches - Occasional Galactorrhea on breast palpation - Physical Examination = Normal - Neuro / Musculoskeletal/ Reflexes = Normal - Serum Prolactin = 1665 ng /ml - (Normal Range = 2 29 ng/ml) Case 1 Which of the following is the most likely cause of this patient s elevated prolactin level? 1. Hypothyroidism 2. Primary Hyperparathyroidism 3. Pregnancy 4. Pituitary Adenoma 2

Pituitary Adenoma Symptoms Headache Vision loss, particularly loss of peripheral vision Nausea and vomiting Fatigue Weakness Amenorrhea Galactorrhea Cold intolerance Constipation Low blood pressure Body hair loss Sexual dysfunction Unintended weight loss or gain Case 2 26 y.o. Female with Fatigue & Weight Gain - Irregular Menstrual Cycle - Galactorrhea x 6 Months - No Change in Vision - Taking no Medications - Small Goiter - Dry Skin - Bilateral Expressive Galactorrhea - Normal Visual Fields - Pregnancy Test = Negative 2 Questions - Prolactin Level = 55 ng/ ml // Normal ( 2 = 20 ng/ml) - Slight Enlargement of Pituitary Gland on MRI Case 2 Which of the following is the most appropriate next step in management of this patient? Which of the following is the next best treatment option? 1) Dopamine Agonist Therapy 2) Re-measure serum prolactin 3) Estrogen/Progesterone therapy 4) Serum TSH and Free T4 1) Administer bromocriptine 2) Use of Oral Contraceptives 3) Administration of L-thyroxine 4) Resection of Pituitary Gland 3

Case 3 16 year old female presents with concerns of overactive thyroid Mother and Sister with similar condition Which of the following are symptoms of hyperthyroidism? 1) Weight Gain 2) Palpitations 3) Dry Skin 4) Constipation Hyperthyroid Symptoms Palpitations Heat intolerance Nervousness Insomnia Breathlessness Increased bowel movements Light or absent menstrual periods Fatigue Fast heart rate Trembling hands Weight loss Muscle weakness Warm moist skin Hair loss Staring gaze 4

Hypothyroid Symptoms Fatigue Weakness Weight gain or increased difficulty losing weight Coarse, dry hair Dry, rough pale skin Hair loss Cold intolerance (you can't tolerate cold temperatures like those around you) Muscle cramps and frequent muscle aches Constipation Depression Irritability Memory loss Abnormal menstrual cycles Decreased libido Case 4 51 y.o. female presents with 2 month history of palpitations, diaphoresis, & tremor. 10 Pound Weight Loss Appears Nervous on Examination Taking no Current Medications Tachycardia at 108 bpm Enlarged / Non-Tender Thyroid Gland Case 4 Which is the best initial test to evaluate the patients hyperthyroidism? 1) Serum TSH 2) Serum Total T4 3) Serum Total T3 4) Thyroid Stimulating immunoglobulin 5

TSH Group Recommendations TSH Group Recommendations USPSTF ATA ACP AAFP AACE Insufficient Evidence for Recommendation ALL Men / Women 35 < & Every 5 Years ALL Women 50 < with 1 or more symptom <60 Recommends Against Routine Screen Asympt Pts Childbearing Age before Pregnancy or 1 st trimester Case 5 45 year old female presents with palpitations, tachycardia, & exophthalmous. - Concerns of Graves disease Which of the Following Statements is true? 1) Serum TSH and Free T4 are Elevated 2) Thyroid Scan Shows a hot nodule 3) Test for Thyroid Antibodies are negative 4) Serum TSH Decreased & Free T4 Elevated 6

Case 6 18 year old female with complaints of fatigue Cold intolerance Dry Skin Constipation Physical Examination Normal Serum TSH = 8.9 (Normal 0.45 4.5) Case 6 What is the next more appropriate step in the evaluation of this patient s thyroid function? 1) Thyroid Scan 2) Start Thyroxine & Check Serum TSH in 8 Weeks 3) Thyroid Ultrasound 4) Serum T4 Level 7

Case 7 45 year old male patient presents to the office for a well check - No complaints or concerns during this visit - History of primary hyperparathyroidism Case 7 Which of the following if the most common patient presentation of primary hyperparathyroidism? 1) Spinal Fracture 2) Osteopenia 3) Kidney Stones 4) Asymptomatic hypercalcemia 5) Acute Renal Failure 8

Hyperparathyroid Symptoms Moans Constipation Nausea Abdominal Pain Peptic Ulcer Disease Stones Kidney Stones Flank Pain Frequent Urination Groans Dementia Depression Confusion Memory Loss Bones Bone Aches / Pains Fractures Spine Curvature Loss of Height Case 8 38 year old male presents with diaphoresis and hypertension. Palpitations for past 2 months History of Medullary Thyroid Cancer BP = 162 / 112 Heart Rate = 112 Pallor in Face and Palms after position change Case 8 What is the most appropriate next step evaluation for this patient? 1) Serum TSH 2) Blood Cultures 3) Thyroid Ultrasound 4) 24 hour Urine for Metanephrine 5) Serum Prolactin 9

5P s for Pheochromocytoma Pressure (hypertension) Pain (headache, chest pain, abdominal pain) Perspiration (diaphoresis) Palpitations Pallor Case 9 From prior case, what other test would you want to consider if you were considering the patient had multiple endocrine neoplasia IIA? 1) BUN/Creatinine 2) PTH 3) Prolactin 4) Testosterone Level MEN I Pancreas Adenomas Pituitary Adenomas Hyperparathyroid MEN IIA Medullary Carcinoma Thyroid Pheochromocytoma Hyperparathyroid MEN IIB Medullary Carcinoma Thyroid Pheochromocytoma Neurofibromas 10

Covered Topics Pituitary Thyroid Parathyroid Other Endocrine Any? s References Picture 1 (Major Endocrine Glands) http://commons.wikimedia.org/wiki/file:illu_endocrine_system.jpg Picture 2 (Thyroid Gland) http://commons.wikimedia.org/wiki/file:thyroid_system.png Picture 3 (Calcium Regulation) http://commons.wikimedia.org/wiki/file:calcium_regulation.svg Picture 4 (Persian Goitered Gazelle) http://commons.wikimedia.org/wiki/file:persian_goitered_gazelle2.jpg Picture (Pituitary) http://commons.wikimedia.org/wiki/file:pituitary_gland_representation.png http://www.uspreventiveservicestaskforce.org/3rduspstf/thyroid/thyrrs.htm Ladenson PW, Singer PA, Ain KB, et al. American Thyroid Association guidelines for detection of thyroid dysfunction. [erratum appears in Arch Intern Med2001 Jan 22;161(2):284]. Arch Intern Med 2000;160(11):1573-5. American College of Physicians. Clinical guideline, part 1. Screening for thyroid disease. Ann Intern Med 1998;129(2):141-3. AACE Thyroid Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Endocrine Prac 2002;8:457-69. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examinations. Leawood, KS: American Academy of Family Physicians; 2002. https://commons.wikimedia.org/wiki/file:roulette_-_detail.jpg 11