endocrine questions for resident

7/31/2019 Endocrine Questions for Resident

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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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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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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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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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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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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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ACE(-) and HCTZ

Above medications replaced with CCB

BP improved but not to target

Normalization o f K level


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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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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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Current medications include

Insulin

Prednisone 10 mg OD

No HRT

ROS:

Menopause at age of 51 yrsLoss of height


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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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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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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




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Investigations :

Free T4 39 nmol/L ( 10-19)

TSH


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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



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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


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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ROS:

Cold intolerance

Decreased libido with erectile dysfunction

No visual complaint

Exam :

Stable vital signsMild pallor

No goiter

Otherwise : unremarkable



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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



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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



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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



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Exam:Weight 50 kg Height 170 cmBP 110/55 , HR 116/min , Afebrile

Cachectic patientNo lymphadenopathy

Breast : unremarkableOtherwise ;not contributing



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Investigations

FPG 5.0 mmol/L

Na 140K 4.0

S. Creatinine 145 (53-115mmol/L)



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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)



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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



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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)



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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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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



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She is married for 13 yrs

Gravida 7 / Para 7 ; youngest is 2 yrs andoldest is 11 yrs

Breast fed all her children



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Exam:

Stable vital signs

Diffuse tenderness over bones

No bone deformities



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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 )


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



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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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endocrine questions for resident

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