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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 1 7/29/2015 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 2 7/29/2015 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 3 7/29/2015 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 4 7/29/2015 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 5 7/29/2015 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 6 7/29/2015 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 7 7/29/2015 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 8 7/29/2015 Hyperparathyroid Symptoms Moans Groans – – – – – – – – 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 9 7/29/2015 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 10 7/29/2015 Covered Topics Thyroid Pituitary 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://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 – • • • • http://commons.wikimedia.org/wiki/File:Pituitary_gland_representation.PNG 11