Targeted Issues In Endocrinology

Targeted Issues in
Endocrinology
Joshua S. Coren, DO, MBA, FACOFP
7/29/2015
Endocrine in 25 Minutes
Joshua S. Coren, D.O., MBA, FACOFP
Chair and Associate Professor, Family Medicine
Rowan University School of Osteopathic Medicine
Outline Goals
Pituitary
Parathyroid
Thyroid
Other Endocrine
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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.
2.
3.
4.
Hypothyroidism
Primary Hyperparathyroidism
Pregnancy
Pituitary Adenoma
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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
2
Small Goiter
Questions
Dry Skin
Bilateral Expressive Galactorrhea
Normal Visual Fields
Pregnancy Test = Negative
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 Which of the following is
the next best treatment
in management of this
option?
patient?
1) Dopamine Agonist Therapy
1) Administer bromocriptine
2) Re-measure serum prolactin
2) Use of Oral Contraceptives
3) Estrogen/Progesterone therapy 3) Administration of L-thyroxine
4) Serum TSH and Free T4
4) Resection of Pituitary Gland
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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)
2)
3)
4)
Weight Gain
Palpitations
Dry Skin
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
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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)
2)
3)
4)
Serum TSH
Serum Total T4
Serum Total T3
Thyroid – Stimulating immunoglobulin
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TSH Group Recommendations
TSH Group Recommendations
USPSTF
Insufficient Evidence for Recommendation
ATA
ALL Men / Women 35 < & Every 5 Years
ACP
ALL Women 50 < with 1 or more symptom
AAFP
<60 Recommends Against Routine Screen Asympt Pts
AACE
Childbearing Age before Pregnancy or 1st trimester
Case 5
45 year old female presents with
palpitations, tachycardia, & exophthalmous.
- Concerns of Graves’ disease
Which of the Following Statements is true?
1)
2)
3)
4)
Serum TSH and Free T4 are Elevated
Thyroid Scan Shows a “hot” nodule
Test for Thyroid Antibodies are negative
Serum TSH Decreased & Free T4 Elevated
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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)
2)
3)
4)
Thyroid Scan
Start Thyroxine & Check Serum TSH in 8 Weeks
Thyroid Ultrasound
Serum T4 Level
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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)
2)
3)
4)
5)
Spinal Fracture
Osteopenia
Kidney Stones
Asymptomatic hypercalcemia
Acute Renal Failure
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Hyperparathyroid Symptoms
Moans
Groans
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–
–
–
–
–
–
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Constipation
Nausea
Abdominal Pain
Peptic Ulcer Disease
Stones
Dementia
Depression
Confusion
Memory Loss
Bones
– Kidney Stones
– Flank Pain
– Frequent Urination
–
–
–
–
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)
2)
3)
4)
5)
Serum TSH
Blood Cutures
Thyroid Ultrasound
24 hour Urine for Metanephrine
Serum Prolactin
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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)
2)
3)
4)
BUN/Creatinine
PTH
Prolactin
Testosterone Level
• MEN I
– Pancreas Adenomas
– Pituitary Adenomas
– Hyperparathyroid
• MEN IIA
– Medullary Carcinoma Thyroid
– Pheochromocytoma
– Hyperparathyroid
• MEN IIB
– Medullary Carcinoma Thyroid
– Pheochromocytoma
– Neurofibromas
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Covered Topics
Thyroid
Pituitary
Parathyroid
Other Endocrine
Any ?’s
References
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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)
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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
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http://commons.wikimedia.org/wiki/File:Pituitary_gland_representation.PNG
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