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INTERNAL MEDICINE BOARD REVIEW
ENDOCRINE SECTION
KING FAHAD SPECIALIST HOSPITAL-DAMMAM
MAY-24-2012
Dr. Mohammad DaoudConsultant Endocrinologist
Internal Medicine Department
KFMMC
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All reflects the standards of care
for diabetic patients Except:
A- BP < 130/80 mmHg
B- LDL- Cholesterol of < 100 mg /dl ( < 2.6 mmol/L )
( < 70 mg /dl {1.8 mmol/L} ; very high risk )
C- Post -prandial capillary PG < 180 mg /dl
( < 10.0 mmol/L)
D- HbA1C < 8.0%
E- Pre-prandial capillary PG 70-130 mg/dl
(3.9 - 7.2 mmol/L)
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Treatment goals for DM patients
A- BP < 130/80 mmHg
B- LDL- Cholesterol of < 100 mg /dl ( < 2.6 mmol/L )
( < 70 mg /dl {1.8 mmol/L} ;very high risk )
C- Post -prandial capillary PG < 180 mg /dl
( < 10.0 mmol/L)
D- HbA1C < 7.0%
E- Pre-prandial capillary PG 70-130 mg/dl
(3.9 - 7.2 mmol/L)
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Diabetes Mellitus
Targets For Control (ADA-2012)Parameter Goal ActionSuggested
AC Glucose
Post-P Glucose
70-130
< 180
140
>180
HS glucose 100-140 160
HbA1c % 8
BP (mmHg.) 130/80 >130/80
LDL-Chol
TG
40 males
>50 females
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A young lady with Polyuria
A 40 yr old female patient presents to yourclinic with symptoms of weakness and
excessive urination
PMH : CAD , Dyslipidemia & HTN on Rx
BP 144/88 BMI = 32 kg /m2
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All can be an initial tests toevaluate this patient complaint
Except:A- Plasma Glucose
B- Serum calcium
C- 24 hr urine volume
D- Water deprivation test
E-Serum and urine osmolarity
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All will establish the DX of DM in
this patient Except:
A- Fasting Plasma Glucose of 126 mg /dl(7.0 mmol/L)
B- 2-hrs Glucose 200 mg/dl(11.1 mmol/L) during OGTTC- Random Glucose of 200 mg/dl
(11.1 mmol/L) with symptoms
D- HbA1C 6.5%
E- Fasting Plasma Glucose of = 120 mg /dl
(6.6 mmol/L)
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Need to know
D.Dx of Polyuria
Diagnostic Criteria of DMVs
Pre-diabetes
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D.Dx of Polyuria(Osmotic or Water diuresis)
Diabetes MellitusDiabetes InsipidusPrimary polydipsia
Hypercalcemia
Others
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FPG of 120 = IFG (Pre DM status )
Pre-diabetesIFG
FPG 100125 mg/dL (5.66.9 mmol/L): IFG
OR
IGT
2-h plasma glucose in the 75-g OGTT
140199 mg/dL (7.811.0 mmol/L): IGTOR
A1C 5.76.4%
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A middle aged male with Polyuria
and Nocturia
A 45 year old male patient
Presents with history of excessive urination for
about 3 months
He describes drinking about 12 bottles of water
( each 700 ml ) over 24 hrs
He has to wake up 5-6 times /night to empty his
bladder
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A middle aged male with Polyuria
and Nocturia
No previous medical illness
No medications on board / or OTC
No history of head trauma or falling down
No history of any prior surgeries
No psychiatric history
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A middle aged male with Polyuria
and Nocturia
Exam:
non-contributing
Labs:
Normal : plasma glucose , serum calcium
Na 146 , Cr 8024 hr urine collection : 6.5 liters
Urine Osmo. = 140 mOsmo / L (300-1000)
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Male with Polyuria and Nocturia
All are proper indications for termination
of water deprivation test Except:
A-Patient becomes hemodynamically unstable
B-Weight loss of > 3-5 %
C-Diluted 2 consecutive urine samples despite
Plasma osmolality 295-300 mOsmo /L
D-Plasma Na 145
E-Urine output of >500 ml/hr
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Further workup
After 8 hrs of Water deprivation
Urine Osmo 140 , 160
Plasma Osmo. 299
Plasma Na 149
dDAVP 10 mcg introduced
Within 2 hr ;urine Osmo= 625 mOsmo/LUrine output : 350 ml to 55 ml/hr
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Least likely underlying etiology of
polyuria in this patient is
A- Sarcoidosis
B- Hypothalamic lesion mass effect
C- Histocytosis X (Langerhans / eosinophilicgranuloma)
D- Nephrogenic DI
E-Idiopathic ( ? Autoimmune) Central DI
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To establish Dx of DI in patient
with Polyuria and Nocturia
High Urine output > 3-4 L / 24 hrs
(>50 ml/kg)
Dilute urine < 300-350 mOsmo/L
Failure to concentrate the urine despite
adequate stimulus ( dehydration)
Pattern of response to exogenous ADH
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Diagnosis of Central and nephrogenic diabetes insipidus
in a patient with polyuria
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Type 2 DM
Insulin Use Indications
A- Symptomatic hyperglycemia on presentation
B- Secondary failure of oral agents
C- Contraindication for oral agents
D- Pregnancy
E- Acute de-compensation or stress
(ex: peri- operative)
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Old Lady with Polyuria
An 85 year old female patient was recentlydiagnosed with DM
She had Polyuria, nocturia, weight loss with aRBG of 455 mg/dl and HbA1c 11.3 %
No family history of DM
Exam : Stable vital signs ; other wiseunremarkable
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Old Lady with PolyuriaRecently Diagnosed with DM
She was started on Insulin twice daily with good
response ;
FPG < 150mg/dl and HbA1c down to 7.4%
Still, she was complaining from poor appetite with no
weight gain
F/Up lab results:
Normal TFT ,CBC : Hb 11 gm/dl
Na 138 , K 4.0 , S.Cr 80
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Old Lady with PolyuriaRecently Diagnosed with DM
The best next step in evaluating this patient:
A- 24 hr urine collection for Cr and ProteinB- Plasma AM Cortisol levelC- CT of upper abdomenD- Serum lipaseE-Gastric emptying study
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Old Lady with PolyuriaRecently Diagnosed with DM
Always think about possible
secondary causes of DM
Like Ca . Pancreas orMets to Pancreas
Look for clues : ex:Cushingoid or Acromegalic features
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Old male with A. Fibrillation
A 70 yr old male patient with long standing DM type 2and Hypertension
Presented to ER with palpitation and dizziness
Vital signs: BP 100/50 HR 140 (irregular , irregular )
ECG: A. Fibrillation with ;ventricular rate of 155 /min
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Old male with A. Fibrillation
A 70 yr old male patient with A. Fibrillation
His baseline labs:
S. Cr 90 (53-115 mmol/L)
,K 4.0 mmol/L
Glucose 8.5 mmol/L
TSH 1.9 (0.4- 4.5 )Free T4 16 (10-19 nmol/L)
FT3 6 (4.7-8.2 pmol/L)
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What about this patient?
A 70 yr old male with Atrial Fibrillation
He was started on Amiodarone
Was
1.916
6
2 weeks later TFT was
repeated and showed
TSH 9.5FT4 11
FT3 2.4
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A 70 yr old male with Atrial Fibrillation
on Amiodarone with deranged TFT
What is your best next action ?
A- Start L-Thyroxin 50 mcg/d and repeat
TFT in 6-8 weeksB- Do thyroid isotope scan
C- No intervention ;Repeat TFT in 2-3 months
D- Measure the thyroid Anti-TPO antibodies
E- Thyroid Ultrasound
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Amiodarone & TFT
Amiodarone is a lipophilic drugRich in iodine ; 30% of tablet weight
A 200 mg tablets ; 65- gm of iodine
Daily requirement 0.15-0.3 mg
One tablet provides up to
40- 100 daysof iodine needs !
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Amiodarone & TFT
It inhibits T 4 T3 (Pit / Peripheral)
Temporary high TSH
Lower T4 and T3
Reset balance in 3 months
Half-life of about 100 daysToxicity can occur well after drug withdrawal
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All are true statement about
pharmacologic Rx of DMExcept
A- Metformin is the cornerstone Rx unless C.I
B- Secondary failure is least with Metformin
C- Glitazones are C.I with CHF stage III-IV
D- Sulfonylurea can cause hypoglycemia and
weight gain
E- Metformin is C.I with renal impairment
(Cr > 1.5 mg/dl) ( Lactic Acidosis Risk)
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Pharmacologic Rx of DM
Type 2 DM is a progressive disease of
Beta Cells reserve loss with time
To date ;no definite treatment that fixes suchissue!
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Contra-indications for Metformin
Renal dysfunction ; males 1.5 mg/dlor 1.4 mg/dL in females
Congestive Heart Failure /on treatment or
hypo perfusion /shock status
Liver disease
Contrast exposure
Acute or chronic metabolic acidosis; DKA
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Young male with Hypertension
A 32 year old male patient
Diagnosed to have HTN 3 months ago
Referred for evaluation ofpossible secondary causes of hypertension
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Young male with Hypertension
He describes history of headache and poor energy
He denies palpitation ,sweating or flushing
No body weight changes reported
No use of alcohol or illicit drugs
Family history : No HTN or hemorrhagic stroke
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Commonest etiology for
secondary HTN is
A- Pheochromocytoma
B- Cushings syndrome
C- Mineralocorticoid excess
D- Reno-vascular etiology
E- Obstructive sleep apnea
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Causes OF Secondary HTN-1
Reno vascular dis.
Pheochromocytoma
AldosteronomaCushings syndrome
Sleep apneasyndrome
Coarctation ofaorta
Oral contraceptives
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Clues for Secondary HTN
Unexplained/Easily provoked hypokalemia
Severe or Resistant HTN
Adrenal Incidentaloma
suggestive clinical picture of a secondarycause e.x : Cushingoid features or classicalpicture of Pheochromocytoma
Suggestive Family History
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Young male with HypertensionExam:
BP 150/110 both arms HR 78 /min regular
No radio-femoral pulse delay
Thyroid : Normal
Chest /CVS Exam : Unremarkable
Skin: No bruises or striae
No buffalo hump or increased supra- clavicularpads of fat
Back to
the case
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Young with Hypertension
Investigations
Normal CBC ,TFT
Na 144K 3.6 (3.6-5.2 mmol/L)
Serum Creatinine 74 ( 60-115 mol /L)
HCO3 34 (22-29 mmol/L)
Calcium 2.4 (2.2-2.6mmol/L
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Young with Hypertension
Investigations
Renal Ultrasound/ Doppler : Normal
Treated with ACE(-) and HCTZ1 WEEK LATER:
BP 148/96Serum K dropped to 3.0 (3.6-5.2 mmol/L)
Serum Creatnine 80 ( 60-115 mmol/L)
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Young with Hypertension
ACE(-) and HCTZ
Above medications replaced with CCB
BP improved but not to target
Normalization o f K level
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Young with Hypertension
Best next in evaluation is:
A- 24 hr urine collection for fractionatedmetanephrines and catecholamines
B- Plasma free metanephrinesC- Plasma Aldosterone and Plasma ReninD- CT scan adrenals
E- Overnight 1 mg Dexamethasonesuppression testing
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Young with Hypertension
Best next in evaluation is:
Hypertension with hypokalemia or easilyprovoked hypokalemia
Alkalosis
R/O state of Mineralocorticoid excess
Conns is the commonest
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Old lady with back pain
A 70- year old lady with history of DM-Type 2 and
Rheumatoid arthritis for many years
Consults you regarding her concerns about beingosteoporotic since her mother had osteoporosis
with hip fracture
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Old lady with back pain
Current medications include
Insulin
Prednisone 10 mg OD
No HRT
ROS:
Menopause at age of 51 yrsLoss of height
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Old lady with back pain
Exam :
Weight 87 kg , Height 162 cm BMI 33 kg/m2
Mild kyphosisNo bone tenderness
Labs:
Calcium 2.25 mmol/L
Albumin 40 gm/L
25-Vitamin D (pending)
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Old lady with back pain
All are risk factors for osteoporosis Except
A- Positive parental history of osteoporosis
B- Rheumatoid arthritis
C-Obesity
D-Postmenopausal state
E- Long term use of glucocorticoids
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Old lady with back pain
The most important risk factors for
osteoporosisA- Positive parental history of osteoporosis
B- Rheumatoid arthritis
C-Obesity
D-Postmenopausal state
E- Long term use of glucocorticoids
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Know the risk factors for osteoporosis
Age / Sex ( Females >>Males)
+ve parental historyPrevious fracturesRheumatoid arthritis
Underweight / Lean body (ht/ wt /BMI)
Postmenopausal state / Hypogonadism
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Know the risk factors for osteoporosis
Glucocorticoids use ( 3 months / 5 mgPrednisolone)
Current SmokingAlcohol ; units/day
Secondary osteoporosis
( Hypo- gonadism or Premature menopause,Mal-absorption, CLD, IBD)
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FRAX tool -12 factors
Age SexHeight WeightCurrent Smoking Alcohol ; units/day
Previous fractures Rheumatoid arthritisParental fracture
Glucocorticoids use ( 3 months / 5 mg Prednisolone)Secondary osteoprosisBMD
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A Man with OsteoporosisA 55 year old male, referred for management of
osteoporosis Dx based on DXA scan ( T-score -3.0 bothspine and hips)
PMHx:
HTN & DM diagnosed 2 yrs ago (On Rx )
ROS: Progressive weight gain over last 3 years
Smoker for 30 yrsDenies any sexual dysfunction
Rx: Metformin 1 gm. BID and Perindopril 5 mg OD
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A Man with Osteoporosis
Exam:BP 144/92 HR 80/min
weight 96 kg Height 168 cm
BMI 34 kg/m2
Moon face changes
Fresh striae over abdomen and extremitiesProximal muscle wasting and weakness
Dark/ pigmented skin
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A Man with Osteoporosis
Labs:Normal :CBC , S. Lytes ,Calcium profile and TFT ,
24 hr urine collection for UFC : 4 times upper
normal
1 mg Dexamethasone suppression test :No suppression
8 mg Dexamethasone suppression test :
No suppression
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A Man with OsteoporosisYour best next step in evaluation of this patient is :
A- Pituitary MRIB- IPSS
C- CRH stimulation testD- Plasma ACTHE- Adrenal CT scan
Plasma ACTH :
110(2-11 pmol /L)
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A Man with OsteoporosisThe least likely etiology /source of this patient
disease is :
A- Pituitary AdenomaB- Pancreatic neuroendocrine tumors
C- Adrenocortical carcinomaD-Bronchial carcinoid tumorE- Ectopic CRH secreting tumor
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A Man with OsteoporosisDiscussion
-The patient has florid Cushings syndrome-Failure to suppress with high
dexamethasone against pituitary source( Cushings disease)
First step in evaluation of confirmed state ofhyper- cortisolemia .Plasma ACTH
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A Man with OsteoporosisDiscussion
-Ectopic source is very likely with history ofsmoking , skin pigmentation , failure of
suppression to high Dexa. Dose
Adrenocortical Ca. = Low ACTH
i
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Common Causes of Cushing Syndrome
Cause % of PatientsaEndogenous Cushing syndrome
ACTH-dependent 75-80
ACTH-secreting pituitary adenomas 60-65
Ectopic ACTH secretion by tumors 10-15CRH-secreting tumors
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Pregnant with Hypothyroidism
Currently she pregnant ( GA 10 weeks)ROS: Excellent compliance to treatment
No complaints
TFT done 2 day ago : TSH 7.3 FT4 11
She is concerned about her babywith this current TFT?
Pregnant with Primary
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g y
Hypothyroidism on Rx
The best statement/action at this stage is ?A- She can be assured/continue same treatment
B- Advise her to increase her intake of sea food
C- The fetus produces adequate T4 at this stage of
pregnancy
D- Increase her L-T4 dose to 125- 150 mcg/day and
repeat TFT in 6 wks
E- No risk for the fetus with such TFT
PREGNANCY THYROID ADAPTATION
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Same alpha-subunit
hCG and TSH
ConsiderableSimilarity
hCG peak effect at 10-12 weekshCG has weak thyroid-stimulating activity
PREGNANCY- THYROID ADAPTATION
hCG and TSH
NORMAL PREGNANCY
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NORMAL PREGNANCY
Trimester-specific reference ranges
The TSH (mU/L) reference ranges can be used:
* First trimester 0.1 to 2.5* Second trimester 0.2 to 3.0
* Third trimester 0.3 to 3.0
Guidelines of the American Thyroid Association (ATA)for the Diagnosis andManagement of Thyroid Disease During Pregnancy and Postpartum
Higher hCG means lower TSH
GA 10 weeks:
TSH 7.3
FT4 11
h id d
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Know the impact of pregnancy on TFT and L-T4
requirement
Trimester-specific reference range
The fetus is almost totally dependent on the
mother for thyroid hormone
Thyroid and Pregnancy
Need to Know
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hi t i ti t ith b l
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Psychiatric patient with abnormal TFT
A 28 year old female patient with history of
schizophrenia presenting with
acute exacerbation of her psychosis
She lost about 10 kg over 4 months
Poor sleeping w palpitation , heat intolerance with
irregular menses
Family history : ++ members with autoimmune
thyroid disease
P hi t i ti t ith b l TFT
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Exam:
HR 124 /minute regular , BP 140/90
Restless , anxious with sweaty palms+ve tremors , lid lag and stare
No exophthalmos+3 brisk reflexes
Thyroid : Not palpable
Psychiatric patient with abnormal TFT
P hi t i ti t ith b l TFT
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Investigations :
Free T4 39 nmol/L ( 10-19)
TSH
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Psychiatric patient with abnormal TFT
P hi t i ti t ith b l TFT
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Psychiatric patient with abnormal TFT
The most likely diagnosis is
A- Struma ovarii
B- Amphetamine abuse
C- Factitious hyperthyroidism
D- Hyper- thyroxinemia due to acute psychosis
E- Hyper- thyroxinemia due to estrogen ingestion
Psychiatric patient with abnormal TFT
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A patient with psychiatric history
Family history of thyroid disease ( ?access to L-T4 Rx)
Impalpable thyroid and
low Tg & low uptake scan
=Factitious hyperthyroidism
Psychiatric patient with abnormal TFT
Discussion
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M l ti t ith f ti
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Male patient with fatigue
A 48 year old male patient presents to you with a
complaint of fatigue and cold intolerance
He is known to have DM type 2 for 10 years and CAD
He underwent CABG 3 months ago ; was complicated
by excessive blood loss and prolonged hypotension for
few hours after which he pulled through ,luckily !!
M l ti t ith f ti
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Male patient with fatigue
ROS:
Cold intolerance
Decreased libido with erectile dysfunction
No visual complaint
Exam :
Stable vital signsMild pallor
No goiter
Otherwise : unremarkable
Male patient with fatigue
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The least likely lab result compatible with his
clinical setting
A- Testosterone 8 (13-30 nmol/L) and LH < 0.1
(1.1-9.0 mIU/ml)B- F.T4 6 (1021 pmol/L ) and TSH 70 (0.4-4.5 mIU/L0)C- Prolactin 2 (4-19 ng/ml )
D- Evening serum cortisol 60 ( 88-440 nmol/L )E-GH undetected
Male patient with fatigue
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This patient setting equals females
Sheehan's syndrome
Think Central
Hypo-Pituitary state :Variable degrees
Cant rely on trophic hormones ;ex:TSH
High TSH = Primary hypothyroidism
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A oman ith eakness
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A woman with weakness
A 45 year old female patient presents to OPDwith
6 months progressive history ofweakness and generalized body aches
A woman with weakness
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A woman with weakness
A45 year old female
She denies any significant medical history
Smoker for 25 years
Documented weight loss of 12 kg over last 6 months
She is not dieting
She has no menses for last 8- months
No medications or supplements on board
A woman with weakness
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A woman with weakness
Exam:Weight 50 kg Height 170 cmBP 110/55 , HR 116/min , Afebrile
Cachectic patientNo lymphadenopathy
Breast : unremarkableOtherwise ;not contributing
A woman with weakness
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A woman with weakness
Investigations
FPG 5.0 mmol/L
Na 140K 4.0
S. Creatinine 145 (53-115mmol/L)
A woman with weakness
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A woman with weakness
Investigations
Calcium 3.0 (2.2-2.6 mmol/L)
Albumin 30 (35-50 g/L)Mg 0.9 (0.7- 1.3 mmol/L)
Phosphorous 0.8 (0.8-1.6 mmol/L)Alkaline Phosphatase 220 (50-136 U/L)
A woman with weakness
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A woman with weakness
Investigations
Serum Prolactin 450 (2-20 ng/ml)
CXR :Rt. sided lung mass
A woman with weakness (1)
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What is your next step in workup of
Hypercalcemia in this patient?
A- Mammogram
B- 25-Vitamin D level
C- Parathyroid hormone level
D- 24 hr urine collection for calcium and Cr.
E- Lung biopsy
A woman with Hypercalcemia and lung mass
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yp g
Investigations Normal Mammogram
25-Vitamin D level : 75 (50-150 nmol/L)
Parathyroid hormone level: 120 (10-65 ng/L)
24 hr urine collection: Calcium 600 mg (15 mmol)
Bronchoscopy : Squamous cell carcinoma
A woman with weakness (2)
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Her most likely etiology of
Hypercalcemia:
A- Breast Cancer
B- Vitamin D Intoxication
C- Primary hyperparathyroidism
D- Familial Hypocalciuric Hypercalcemia (FHH)
E- Squamous cell carcinoma (Para neoplastic)
A woman with weakness (3)
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All are possible components of MEN-1
except:
A- Prolcatinoma
B-Tongue Neuromas
C- Primary hyperparathyroidism
D- Pancreatic tumors (Gastrinoma)
E- Acromegaly
Evaluation of Hypercalcemia
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Evaluation of Hypercalcemia
PTH mediated Vs.non-PTH mediated
Squamous cell carcinoma /PTHrP ?
Coexisting tumors
Vitamin D Intoxicationsuppressed PTH
Familial Hypocalciuric Hypercalcemia (FHH): lowurinary calcium
Diagnostic approach to Hypercalcemia
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Intact PTH
pH PTH FHH
PTHrp and Vit. D metabolites
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A lady with Goiter
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A lady with Goiter
A 45 yr old Saudi female patient from Khobar-underwent a second thyroid surgery for managinga large goiter
Goiter was extending retrosternaly with pressuresymptoms with diffuse lymph nodes enlargement
Histopathology proved to be papillary thyroid
cancer (after an initial subtotal thyroidectomy)
A lady with Goiter
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A lady with Goiter
Past Medical History:
-History of gastric bypass surgery 2 yrs ago for
management of morbid obesity
-She has poor compliance for her prescribed
supplements
-History of use of PPI for management of GERD
A lady with Goiter
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A lady with Goiter
Post Operatively :
12 hrs after surgery she was complaining from
numbness of upper and lower extremities with
muscle twitches
On exam:
Body weight 72 kg
She had carpal spasm while BP was measured
A lady with Goiter
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A lady with Goiter
Post Operative Labs:
Serum Calcium 1.55 mmol/L (6.2 mg/dl)Albumin 38
Phoshporous low -normal
Alkaline Phosphatase high -normal
A lady with Goiter
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All are characteristic of a patient with higher risk of
Post-thyroidectomy symptomatic hypocalcaemiaEXCEPT
A- Large goiter
B- History of Hypothyroidism
C-Reoperation
D-Pre-Op low calcium or vitamin D levels
E-Calcium malabsorption
Higher risk (Predictors) of
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Post-thyroidectomy symptomatic
hypocalcaemia
Large goiter
Reoperation
LymphadenectomyGraves disease
Coexistent Primary Hyper PTH
Pre-Op low calcium or vitamin D levels
Breast feeding
Calcium malabsoption; PPI /Bypass surgery/Celiac
All are appropriate steps in management of
this patient hypocalcaemia EXCEPT
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this patient hypocalcaemiaEXCEPT
A- Measure PTH and Vitamin D levels
B- Two vials of Calcium Chloride 10% over 20 minutes
and re-measure calcium after 8-12 hrs
C- Two vials of Ca- Gluconate 10% then IV infusion
(5-6 vials in half liter D5W at rate of 70 ml/hr)
D- Concomitant oral Calcium and Vitamin supplement
E- Measure Mg level and supplement as needed
Management of Symptomatic
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Calcium Chloride 10% is highly concentrated
(270 + mg/vial) and should be avoided
.extravasations risk
Ca- Gluconate 10% = 93 mg/vial
Established formula for managing symptomatic
hypocalcaemia = 5-6 vials in half liter D5W at rate of70 ml/hr )
Hypocalcaemia
Management of Symptomatic
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Hypocalcaemia
Pre-existing Hyper-PTH Vitamin D def. means morelikely hood for post-op Hypocalcemia
Hypo-Mgshould be fixed to at same time ;Impairs PTH secretion and contributes to PTH
resistance
Concomitant oral Calcium and Vitaminsupplementbut not adequate on its own at leastearly on
Calcium Content
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Calcium Content
Type , Amount Elemental Calcium
1gm Ca Gluconate 93 mg
1gm Ca Chloride 273 mg
1250 mg Ca Carbonate (40% Ca) 500 mg
1900 mg Ca Citrate (21% Ca) 400 mg
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Young lady with weakness
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Young lady with weakness
A30 yr old Saudi female presents to your clinic withweakness and diffuse body aches
She has no past medical history
Regular menses
No medication on board
She was worried about osteoporosis since her
mother has it
Young lady with weakness
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Young lady with weakness
She is married for 13 yrs
Gravida 7 / Para 7 ; youngest is 2 yrs andoldest is 11 yrs
Breast fed all her children
Young lady with weakness
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Young lady with weakness
Exam:
Stable vital signs
Diffuse tenderness over bones
No bone deformities
Young lady with weakness
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Young lady with weakness
Labs :Hb 10.3 g/L
Chemistry:
Na 136 , K 4 , Cr 77
Calcium 2.1 (2.2-2.6 mmol/L)
Phosphorous 0.8 (0.8-1.3 mmol/L)
Alkaline phoshpatase 300 (50-136 u/L )
Young lady with weakness
t lik l di i i
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Most likely diagnosis is:
A- Sickle cell disease with VOC
B- Osteoporosis
C- Osteomalacia with vitamin D deficiency
D- Polymyalgia Rhematica
E- Primary Hypo- parathyroidism
Young lady with weakness
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Most likely diagnosis is:
Osteomalacia with vitamin D deficiency
Vitamin D deficiency is so common in KSA
Up to 80% prevalence in females (many studies)Up to 40 % prevalence in males
Low calcium , low phosphorous and high alkaline
phosphatase .with secondary hyper PTH .makes the story
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