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Transcript
Group 4
(Melissa Carabrese, Kira Piccone, Sophia Wang, Erika Sakkestad)
Anatomy & Physiology II
Professor Kollmeier
27 February 2014
Mary’s Aching Head – Final Report
Mary Keeper is a 41-year-old, female patient who has been complaining of re-occurring
headaches for the past month and trouble sleeping has been a recent outcome. She has seen her
physician, Dr. Nee, for a total of three times ever since her symptoms had started surfacing.
During the first visit, Dr. Nee performed a physical examination and ordered Mary to have a
blood chemistry, thyroid, and endocrine test prior to her next follow-up visit in order to review
the blood lab results. The week after, Mary returned to the doctor’s office to discuss her results
in hopes to gain more insight on her symptoms. Throughout Mary’s results, there are concerns
with her T3 and T4 values, indicating that Mary may be suffering from an endocrine
dysfunction. Additional blood work was done to help with a final diagnosis. In terms of Mary’s
diagnosis, she has a benign, anterior pituitary adenoma which has lead to Grave’s disease linked
with hyperthyroidism.
During the initial physical examination, issues specifically arose in the head and neck
area. Mary shows symptoms of lid lag where the upper eye lid is delayed when instructed to look
downward. This is an example of an ophthalmic manifestation called hypermetabolic which is
linked to hyperthyroidism from Grave’s Disease in this instance. Excess thyroid hormone causes
the upper eyelids to retract (Trobe 2009). A study was done with 120 patients with thyroid
disease and 43% had lid lag. In addition to lid lag, she experiences bitemporal hemianopsia
which is a very common result from pituitary tumors. Mary portrays blindness in her lateral
visual fields. An expanding mass on the pituitary is strong evidence for her re-occurring
headaches in which they tend to be worse when first awakened (Willacy and Tidy 2010).
Dilation of the left pupil is also noticeable. If the nerves around the tumor on the pituitary are
affected, it is an explanation for the pupil enlargement. In addition to that, the oculomotor (III)
nerve can be affected by a tumor and cause her lateral deviation of the left eye (Thomas 2012).
Mary’s blood chemistry results showed that her calcium as well as her parathyroid
hormone values were above the normal limits meaning that she is a strong candidate for primary
hyperparathyroidism. A benign tumor on her parathyroid gland can explain the above normal
results (Collip 1924). The increased calcium level was the only test that brought concern in the
areas of cholesterol, osmolality and urea nitrogen. When focusing on osmolality, it measures the
concentration of all chemical particles found in the plasma of blood. Mary’s levels came back
within range at 280 mOsm/kg/water. Osmolality evaluates water balance within the body and
concentration amongst urine and stool. If levels get too high, the body releases an antidiuretic
hormone and sends a message to the kidneys to reabsorb water, allow the blood to become more
diluted and return to normal (Dugdale 2010).
Dr. John Krusz, an expert in the fields of headache and pain management, was
interviewed by Teri Robert and suggested that patients with headache or migraine issues should
have blood work to check thyroid, cortisol, and other endocrine levels. He also recommends that
free T3 and T4 should be checked since the TSH test might not reveal all problems (Robert
2006). From that information, it is reassuring to see that Mary’s tests covered those areas. Her
blood thyroid results said that her T3-total, T4-free, and T4-total values were all above normal
limits. Since Mary’s T3 values were above normal limits, there are multiple thyroid issues that
Mary may have. These thyroid issues include: Graves’ Disease, hyperthyroidism, and toxic
nodular goiter. Hyperthyroidism is when the thyroid gland produces excess hormone because it
is overactive. Grave’s Disease is the most common cause of hyperthyroidism. This disease is
when the body’s immune system creates antibodies that attach to the thyroid gland, which then
causes the thyroid to make excess of that hormone. Symptoms of hyperthyroidism include hand
tremors, sleeping problems, losing weight, fatigue, eye problems, and thyroid gland swelling
(Topiwala 2014). Toxic nodular goiter is when lumps develop in the thyroid gland, which
contain abnormal thyroid tissue causing excess hormone to be made (Kenny and Knott). T4-free
is the thyroxine that is unbound to protein and free to circulate in blood. When elevated, some
indications include hyperthyroidism, thyroiditis (an inflammation of the thyroid gland), toxic
nodular goiter, and high levels of protein (Holm). Usually, a T4 test is ordered to check thyroid
function, specifically the effects of TSH and T3. They are also ordered if a doctor sees signs of
thyroid disorder, including hyperthyroidism, thyrotoxic periodic paralysis, and thyroid nodules.
T4-total measures the unbound and bound T4. High levels of T4-total is seen in patients who are
on estrogen medication as well as during pregnancy (Topiwala 2014). Because medications,
pregnancy, and high levels of iodine affect levels of T4-total, it is important that results from
other tests are looked at. Her TBG value is also above normal limits and her TSH was
undetectable. High levels of TBG could be caused by high levels of T3 and T4 because TBG is a
carrier protein that binds T3 and T4 together in the bloodstream. High levels of TBG indicate a
possible overactive thyroid gland (Ticchio 2008). Undetectable levels of TSH could also result in
hyperthyroidism (Spencer et al 1987). Studies show that patients who suffer from
hyperthyroidism also suffer from chronic headaches (Iwasaki 1991).
Lastly, Mary’s blood endocrine results shows that her ACTH value is below the normal
limits, her Beta-hCG value is normal for a non-pregnant woman, and her Prolactin value is
within normal limits. Because her ACTH value is below normal limits, it is likely that the
pituitary is not producing enough of this hormone and a tumor is present. The tumor can affect
the pituitary gland and its ability to produce hormones. These hormones then affect how other
glands function and since there is a deficiency in ACTH there may be adrenal insufficiencies.
After reviewing Mary’s blood results, Dr. Nee ordered hematology tests and arranged a followup appointment for Mary the following week. In receiving the hematology results, the blood lab
results indicated that Mary’s PTH, LH, estrogen, and FSH values are all above the normal limits,
but her GH value is below the normal limits.
After thorough research of Mary’s final blood result levels, she seems to be experiencing
a pituitary tumor which is triggering her hyperthyroidism. Specifically, we can diagnose her
hyperthyroidism as primary hyperthyroidism especially since Grave’s disease is the most
common form. A pituitary tumor causes your body to produce a very low level of hormone or
too much hormone in Mary’s case. Some symptoms include unexplained weight loss, visual field
loss, weakness and headaches (Mayo 2012). These specific symptoms leading to a pituitary
tumor are the primary symptoms Mary has been experiencing the past few weeks. However, to
get a valid confirmation of the diagnosis, Mary will have to take cortisol level tests. Cortisol tests
may reveal problems with the adrenal or pituitary gland. If the pituitary gland secretes ACTH,
cortisol levels will increase in response to ACTH being secreted. Most of the endocrine tests
already evaluated reveal information that bring us close to a concrete diagnosis. Since Mary is
experiencing a pituitary tumor that is setting off her hyperthyroidism then she can undergo
radiation therapy to help shrink the tumor (Eckman). Other standard treatments are
chemotherapy, surgery, or drug therapy. These treatment options depend on the type and size of
the tumor among many other factors. One of the factors is whether the tumor is causing vision
problems, in which it is, and another is if the tumor is spreading into the brain or spinal cord.
Further tests are done to rule out if the tumor is, or is not, spreading into the central nervous
system and that is done with an MRI (magnetic resonance imaging). From the MRI, the size of
the pituitary can be established in which many are microadenomas; smaller than a centimeter
(Pituitary Tumor Treament, 2014). Treatments for hyperthyroidism include radiation iodine and
antithyroid medicine. Antithyroid medication prevents the synthesis of thyroid hormone while
the radiation iodine destroys the thyroid production of cells (Krucik 2012).
Overall, Mary Keeper’s test results and symptoms led us to conclude that she is suffering
from more than one dysfunction. Her diagnosis incorporates a benign, anterior pituitary adenoma
which is a major source to the headaches that initially brought her to see Dr. Nee. After further
evaluation, Mary has Grave’s disease linked with hyperthyroidism. Through treatments such as
radiation iodine and antithyroid medication for hyperthyroidism and radiation, chemotherapy or
surgery for the pituitary tumor, we expect Mary will be feeling better in time.
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