Endocrin........FML
A 1-year-old boy presents to pediatrics clinic for a well-child visit. He has no complaints. He has a cleft palate and an abnormal facial appearance. He has been riddled with recurrent infections and is followed by cardiology for a ventricular septal defect (VSD). Vital signs are stable, and the patient's physical exam is benign. If this patient's medical history is part of a larger syndrome, what might one also discover that is consistent with the manifestations of this syndrome?
A positive Chvostek's sign, Hypoparathyroidism
) A 60-year-old man presents to the emergency room with a chief complaint of constipation. His history is also significant for weakness, a dry cough, weight loss, recurrent kidney stones, and changes in his mood. He has a 30 pack-year history of smoking. A chest x-ray reveals a lung mass. Labs reveal a calcium of 14. What is the first step in management?
Administer intravenous fluids, dx hypercalcemia
A 29-year-old patient presents to her primary care physician with persistent amenorrhea and inability to breastfeed over the last 5 months. She says that she has also been very tired since her baby was born and this fatigue was accompanied by an inability to deal with cold weather despite having no problem with cold prior to becoming pregnant. She has gained an additional 5 pounds since delivery. Review of her hospital records reveals that she had a vaginal delivery that was complicated by severe hemorrhage and episodes of hypotension. Which of the following hormone levels is most likely to be normal in this patient?
Aldosterone Ddx Sheenhan Syndrome
A 32-year-old female presents to her obstetrician 3 weeks postpartum for failure to lactate. Of note, she has been unable to tolerate cold environments since the birth of her child. Review of systems is positive for fatigue, lightheadedness, and a 3-pound weight gain over the last 3 weeks. Her delivery was complicated by placenta accreta with postpartum blood loss. Her newborn infant is doing well on formula. She denies any personal or family history of thyroid disease. Physical exam is overall unremarkable. On a panel of hormone testing, which of the following levels is most likely to be normal in this patient?
Aldosterone Ddx Sheenhan Syndrome
An 8-year-old boy presents to the emergency department with intermittent muscle spasms that have been getting worse over the last two days. He is under the growth curve for his age and has had dental problems throughout childhood but is otherwise healthy. Physical exam reveals wrist spasms when a blood pressure is taken as well as shortened 4th and 5th digits. Tapping over the facial nerve elicits contraction of facial muscles. Based on clinical suspicion a panel of calcium tests are obtained. Which of the following combinations of serum calcium and parathyroid hormone (PTH) levels would be most likely in this patient (choices seen in Figure A)
C, Hypoparathyroidism
A 64-year-old female with a history of end-stage renal disease presents to her primary care physician complaining of weakness. She reports a six-month history of progressive weakness accompanied by occasional dull aching pain in her arms, legs, and lower back. She has also started to increase her fiber intake because of occasional strained bowel movements. Her past medical history is notable for poorly controlled diabetes, major depressive disorder, and obesity. She takes insulin and sertraline. She has a twenty pack-year smoking history and drinks alcohol socially. Her temperature is 98.5°F (36.9°C), blood pressure is 130/85 mmHg, pulse is 80/min, and respirations are 16/min. Laboratory findings are shown below: Serum: Na+: 138 mEq/L Cl-: 99 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 20 mg/dL Glucose: 140 mg/dL Creatinine: 2.0 mg/dL Parathyroid hormone: 720 µU/mL Ca2+: 11.1 mg/dL Phosphorus (inorganic): 4.8 mg/dl A medication with which of the following mechanisms of action is most likely indicated to address this patient's symptoms?
Calcimimetic agent, dx-Hyperparathyroidism
A 52-year-old woman presents to her primary care physician complaining of 3 weeks of persistent thirst despite consumption of increased quantities of water. She also admits that she has had increased frequency of urination during the same time period. A basic metabolic panel is performed which reveals mild hypernatremia and a normal glucose level. Urine electrolytes are then obtained which shows a very low urine osmolality that does not correct when a water deprivation test is performed. Blood tests reveal an undetectable level of antidiuretic hormone (ADH). Based on this information, what is the most likely cause of this patient's symptoms?
Central diabetes insipidus, Ddx-Diabetes Insipidus
A 6-year-old boy presents to your office with loss of his peripheral vision. His mother discovered this because he was almost struck by a vehicle that "he couldn't see at all". In addition, he has been complaining of a headache for the last several weeks and had an episode of vomiting 2 days ago. He has a family history of migraines in his mother and grandmother. He is currently in the 80th percentile for height and weight. On physical exam his temperature is 99°F (37.2°C), blood pressure is 110/75 mmHg, pulse is 100/min, respirations are 19/min, and pulse oximetry is 99% on room air. He is uncooperative for the rest of the physical exam. During workup, a lesion is found in this patient. Which of the following would most likely be seen during histopathologic analysis?
Cholesterol crystals and calcification, Ddx- Craniopharyngioma
A 2-month-old boy is being evaluated for a heart murmur and moderate respiratory distress. His mother passed all of her routine prenatal screening exams, and the delivery was uncomplicated. On exam, the infant is noted to have a long, narrow face and a small mouth with a cleft palate. His right cheek also seems to spasm when it is palpated by the physician. The cardiac exam reveals a holosystolic murmur. Labs are noteworthy for low calcium and low parathyroid hormone levels, and chest radiograph reveals absent thymic shadow (Figure A). What is the most likely genetic abnormality present in this infant?
Chromosome 22q11.2 deletion, Hypoparathyroidism
A 41-year-old woman is brought to the emergency department by ambulance because of a sudden onset severe headache. On presentation, the patient also says that she is not able to see well. Physical examination shows ptosis of the right eye with a dilated pupil that is deviated inferiorly and laterally. Based on the clinical presentation, neurosurgery is immediately consulted, and the patient is taken for an early trans-sphenoidal surgical decompression. Which of the following will also most likely need to be supplemented in this patient?
Corticosteroids Ddx-Pituitary Apoplexy
A 25-year old Caucasian female presents with symptoms of Graves' disease. Her doctor prescribes medications and sends the patient home. After two months of therapy, the patient returns upset that her exophthalmos has not gone away. Which of the following drugs should the physician have prescribed to treat the exophthalmos?
Corticosteroids, Dx- Gaves Disease
A 16-year-old girl presents with primary amenorrhea, galactorrhea, and mild headaches. Ophthalmologic examination reveals loss of vision in the right eye (20/40).
Craniopharyngioma
A 2-year-old girl presents with a 2- to 3-week history of nausea, vomiting, and an enlarging head. Physical exam reveals megacephaly and poor visual regard (acuity 20/200).
Craniopharyngioma
A 6-year-old boy has had a daily dull headache for the past 6 months. He says that it is a continuous, dull headache that increases a bit every day. He can't focus on playing with friends at school anymore due to the pain. On physical exam, his physician is concerned when the patient's visual field is notably decreased bitemporally. Additionally, physical exam reveals papilledema bilaterally. A stat CT scan is done, revealing suprasellar calcifications.
Craniopharyngioma
A 34-year-old woman presents with complaints of weight gain and irregular menses for the last several years. She has gained 20 kg over the past 3 years and feels that most of the weight gain is in her abdomen and face. She notes bruising without significant trauma, difficulty rising from a chair, and proximal muscle wasting. She was diagnosed with type 2 diabetes and hypertension 1 year ago.
Cushing Syndrome
A 54-year-old man presents for evaluation of an incidentally discovered adrenal nodule. He underwent a CT scan of the abdomen for evaluation of abdominal pain, which was negative except for a 2 cm well-circumscribed, low-density (2 Hounsfield units) nodule in the right adrenal gland. He reports weight gain of 15 kg over the past 4 years. He has difficult-to-control type 2 diabetes and hypertension. He has had 2 episodes of renal colic in the last 5 years.
Cushing Syndrome
A 9-year-old boy presents with polydipsia, polyuria, and a serum osmolality of 325 mOsm/L. A neurologic examination reveals bitemporal hemianopia. The lesion is believed to be derived from Rathke's pouch remnants. Which of the following is the most likely histologic finding?
Cystic spaces, Ddx- Craniopharyngioma
A 25-year-old previously healthy woman presents to her PCP reporting cessation of menses for the past 6 months. Previously, her period occurred regularly, every 30 days. She also complains of decreased peripheral vision, most noticeably when she is driving her car. She denies any recent sexual activity and a pregnancy test is negative. Upon further work-up, what other physical findings may be discovered?
Decreased bone density, Ddx Prolactinoma
A 32-year-old woman presents to her primary care doctor complaining of increased fatigue and cold intolerance after her recent delivery. The patient delivered a healthy 39-week-old boy 3 weeks ago via spontaneous vaginal delivery. Delivery was complicated by postpartum hemorrhage requiring admission to the intensive care unit with blood transfusions. Pregnancy was otherwise uneventful, and the baby is healthy. The mother has had some difficulty with lactation, but is able to supplement her breast milk with formula feeds. On exam, her temperature is 97.7°F (36.5°C), blood pressure is 112/78 mmHg, pulse is 62/min, and respirations are 12/min. The patient does not have any neck masses or lymphadenopathy; however, her skin appears dry and rough. Which of the following serum lab abnormalities may be expected?
Decreased prolactin—Ddx Sheehan Syndrome
A 52-year-old woman presents to her primary care physician with symptoms of heat intolerance, unintentional weight loss, feelings of anxiety, and excessive energy that hinder her from falling asleep at night. On physical exam, the patient is found to have mildly protuberant eyes bilaterally as well as discoloration and swelling of her shins. Which of the following lab results would most likely be present in this patient?
Decreased serum TSH, Dx- Gaves Disease
A 69-year-old man comes to the office because of headaches that have been progressively worsening over the past 7 months. He describes the pain as a constant ache that is difficult to localize. He has had to take ibuprofen in order to sleep comfortably for the past two weeks. His regular medications include only sildenafil, which he has been taking for the past five years. He denies alcohol and tobacco use. Physical examination shows bilateral nontender, firm enlargement of the patient's breasts that is symmetrical relative to the nipples. Palpation of the axillary lymph nodes shows no abnormalities. Which of the following features is most consistent with this patient's underlying condition?
Decreased serum follicle-stimulating hormone (FSH), Dx-Hyperprolactinemia due to prolactinoma
A 10-week-old female infant born at home presents to the pediatrician because her mother is worried that "she sleeps too much, always feels cold, and does not have bowel movements very frequently." On physical exam, the child has hypotonia, slight to mild jaundice, and the following features (Figure A & B). Which of the following lab findings would be seen in this patient?
Decreased total & free T4, increased TSH, Dx- Congenital Hypothyroidism (Cretinism)
A 57-year-old female with history of Graves' disease presents to your clinic for followup. Over the last several months, she has been experiencing dry, irritated eyes, bilateral eye pain, and double vision. Her eyes have the following appearance (Figure A). What is the mechanism of the patient's proptosis?
Deposition of collagen fibrils and glycosaminoglycans
25-year-old male complains of an unabated thirst that began three weeks ago. He is constantly drinking and goes to the bathroom around five times a night. He has lost five pounds over the last few weeks and is on lithium for a bipolar disorder. His BP is 115/70.
Diabetes Insipidus
A 42-year-old man undergoes transsphenoidal surgery for a large, nonfunctioning pituitary macroadenoma. Preoperatively, dynamic pituitary hormone tests were normal, as was his fluid intake and output. Two days following surgery he developed acute polyuria, extreme thirst, and polydipsia. His urine output over the next 24 hours was 6 liters, with frequent nocturia.
Diabetes Insipidus
A 75-year-old woman presents to her family physician with a 6-month history of progressive fatigue and malaise with polyuria, polydipsia, and nocturia. She has a longstanding history of bipolar affective disorder, and has been receiving lithium for the past 15 years.
Diabetes Insipidus
A obstetrician is working in a developing country to help promote maternal health and fetal well being. While there, he delivers a baby who he suspects has congenital hypothyroidism, most likely caused by inadequate maternal iodine intake. Which of the following signs and symptoms would NOT be expected to be observed in this child?
Diarrhea, Dx-Congenital Hypothyroidism (Cretinism)
A 29-year-old female visits her gynecologist because of an inability to conceive with her husband. Past medical history reveals that she has been amenorrheic for several months, and she complains of frequent white nipple discharge. Urine tests for beta-HCG are negative. A receptor agonist for which of the following neurotransmitters would be most likely to treat her condition:
Dopamine-Ddx Prolactinoma
A 25-year-old female presents with recent muscle weakness, fatigue, and constipation. Physical examination reveals a bradycardic patient with cool, dry skin. Which of the following lab values would be most likely to be present with this patient's presentation?
Elevated serum CK, Dx-Hypothyroidism
A 65-year-old female with chronic renal failure presents with recent onset of bone pain. Serum analysis reveals decreased levels of calcium and elevated levels of parathyroid hormone. One of the mechanisms driving the elevated PTH is most similar to that seen in:
End stage liver failure, dx-Secondary Hyperparathyroidism
A 25-year-old Hispanic male presents with heat intolerance and recent weight loss. Serum analysis shows increased levels of T4 and T3, as well as the presence of thyroglobulin-stimulating immunoglobulins. The patient is found to be tachycardic and has marked edema and waxy discoloration in his legs. Which of the following would be consistent with this patient's disease?
Exophthalmos, Dx- Gaves Disease
, follicle-stimulating hormone
FSH
A 15-year-old girl presents with primary amenorrhea and accelerated growth. On physical examination, her height is above the 90th percentile, her pubertal development is evaluated at Tanner stage 2, and she has soft-tissue swelling. Laboratory workup reveals a moderately elevated serum prolactin concentration of 44 micrograms/L (normal, <20 micrograms/L) and an elevated IGF-1 level of 1525 micrograms/L (normal for age, 198-551 micrograms/L). Pituitary MRI shows a 15 mm pituitary mass without parasellar extension.
Gigantism/Acromegaly
A 47-year-old man presents with arthritic pain of knees and hips, soft-tissue swelling, and excessive sweating. He also noticed progressive enlargement of the hands and feet. He has been taking antihypertensive medication for the past 3 years. On physical examination, he has coarse facial features with prognathism and prominent supraorbital ridges. The tongue is enlarged and the fingers are thickened. His wife complains that he frequently snores. Laboratory workup reveals an elevated plasma insulin-like growth factor 1 (IGF-1) concentration of 560 micrograms/L (normal for age, 120-235 micrograms/L) and a basal plasma growth hormone level of 15 micrograms/L. MRI examination of the sella turcica region shows a 14 mm pituitary mass with right cavernous sinus invasion.
Gigantism/Acromegaly
A 52 year-old man complains of increased hat size and headaches when he wakes up in the morning. Physical exam reveals mild diastolic hypertension, prominant jaw with spaces between the teeth, large hands and feet, and generalized muscle weakness.
Gigantism/Acromegaly
A 37-year-old man presents to his primary care physician because he has had constipation for the last several weeks. He has also been feeling lethargic and complains that this winter has been particularly cold. He also complains that he has been gaining weight despite no change in his normal activities. He reveals that two months prior to presentation he had what felt like the flu for which he took tylenol and did not seek medical attention. Several days after this he developed anterior neck pain. Which of the following findings would most likely be seen on biopsy of this patient's abnormality?
Granulomatous inflammation, Dx-Subacute Thyroiditis (de Quervain)
A 34-year-old woman presents to the physician's office with complaints of weight loss and sweatiness. She states that despite a ravenous appetite, she has lost 4 pounds this past month. In addition she states that she has been more sweaty lately, and unable to cool down in rooms that others find comfortable. On physical exam you see an anxious and fidgety woman who has a very prominent gaze with protuberant eyes.
Graves Disease
A 38-year-old woman, who in the past had tried to lose weight without success, is happy to see that in the last 2 months she has lost 25 pounds. She also has difficulty sleeping at night. Her husband complains that she is keeping the house very cool. She recently consulted her ophthalmologist because of redness and watering of the eyes. Eye drops were not helpful. She consults her doctor for fatigue and anxiety, palpitations, and easy fatigability. On physical examination, her pulse rate is 100 bpm and her thyroid is slightly enlarged. Conjunctivae are red and she has a stare.
Graves disease
A 58-year-old Caucasian female presents to her primary care physician with concerns about several recent health changes. The patient has recently gained weight and can't seem to exercise like she used to. She also notes that her thinking seems slow. Physical examination shows thickened, dry skin. Serum analysis confirms the physician's suspicions. Which of the following findings was most helpful in the diagnosis?
High TSH, Dx-Hypothyroidism
A 28-year-old G1P0 woman comes to the emergency department complaining that her water just broke. She reports irregular prenatal care due to her erratic schedule. She is also unsure of her gestational age but claims that her belly began to show shortly after she received her thyroidectomy for her Graves disease about 9 months ago. She denies any known fevers, chills, abnormal vaginal discharge/bleeding, or sexually transmitted infections. She develops frequent and regular contractions and subsequently goes into active labor. A fetus was later vaginally delivered with a fetal heart rate of 180 bpm. A neonatal physical examination demonstrates a lack of a sagittal cranial suture and an APGAR score of 8 and 8, at 1 and 5 minutes respectively. What findings would you expect in the baby?
High levels of free T4 and total T3, Dx- Gaves Disease
A 63-year-old woman is brought in by her family for progressive fatigue and confusion. Past medical history is notable for ovarian cancer. Physical examination reveals dry mucous membranes. Admission labs are significant for an elevated adjusted serum calcium of 12.8 mg/dL, a low-normal albumin level, a low-normal phosphorus level, and elevated alkaline phosphatase. Hypercalcemia workup reveals a suppressed parathyroid hormone, an elevated parathyroid hormone-related peptide (PTHrP), and a low-normal calcitriol (1,25-dihydroxyvitamin D) level.
Hypercalcemia of malignancy
55-year-old woman has hypercalcemia discovered as an incidental finding during normal routine physical examination. A hand radiograph is shown at right.
Hyperparathyroidism
A 16-year-old girl presents with fatigue and reports missing her period for the past several months though her prior menses were regular. She is short for her age. Her mother has been worried since her daughter started bumping into the furniture around the house. You perform a visual field in the office which reveals the following (Figure A). Vital signs are stable with the exception of blood pressure which is slightly lower than her baseline. The remainder of her physical examination is unremarkable. Regarding this patient, one would also expect to find:
Hypoglycemia, General Hypopituitarism
A 45-year-old woman has a total thyroidectomy for papillary carcinoma. Ten hours after the operation she complains of perioral and digital paresthesias. Her condition rapidly deteriorates with a sense of constriction in her throat and difficulty on inspiration.
Hypoparathyroidism
A 52-year-old woman is operated on for long-term primary hyperparathyroidism diagnosed by serum calcium of 12.6 mg/dL (3.15 mmol/L) and PTH of 270 picograms/mL. Her intraoperative PTH after resection of a 2-gram adenoma was 12 picograms/mL. Twelve hours after her procedure, she complains of paresthesias and anxiety. Her serum calcium is 6.8 mg/dL (1.7 mmol/L).
Hypoparathyroidism
A 32-year-old woman presents to her doctor with a 10-month history of depression, hot flashes, weight gain, reduced libido, lethargy, cold intolerance, and amenorrhea. She delivered a healthy baby boy 10 months ago; however, the delivery was complicated by a significant postpartum hemorrhage requiring multiple blood transfusions. She was unable to breastfeed her baby and has been amenorrheic since that time. Physical exam is remarkable for a flat affect, bradycardia, weight loss, and delayed relaxation of her reflexes.
Hypopituitarism
A 40-year-old man has a 12-month history of progressive headaches, weight loss, poor appetite, lethargy, cold intolerance, and erectile dysfunction. He has difficulty seeing the periphery when driving his car. Physical exam is remarkable for bradycardia, gynecomastia, scant body hair, delayed relaxation of his reflexes, and bitemporal hemianopia.
Hypopituitarism
A 45 year-old gentleman presents to his primary care physician complaining of wrist pain and is diagnosed with carpal tunnel syndrome. Upon further questioning, the patient admits that he has recently been outgrowing his gloves and shoes and has had to purchase a new hat as well due to increased head size. Upon exam, he is found to have new mild hypertension and on basic labs he is found to be hyperglycemic. Which of the following is the best blood test to diagnose his suspected disorder?
IGF1 Level - Ddx Gigantism/Acromegaly
A 23-year-old male presents with complaints of polydipsia and frequent, large-volume urination. Laboratory testing does not demonstrate any evidence of diabetes; however, a reduced urine osmolality of 120 mOsm/L is measured. Which of the following findings on a desmopressin test would be most consistent with a diagnosis of central diabetes insipidus?
Increase in urine osmolality to 400 mOsm/L following vasopressin administration, Ddx-Diabetes Insipidus
A 52-year-old female presents to clinic complaining of sudden onset of flank tenderness that was fluctuating and radiating into her groin. Laboratory analysis reveals a serum calcium of 12.4 (normal 8.4-10.2) and a serum phosphorous of 2.5 (normal 2.7-4.5) and a chloride:phosphorous ratio >33. You suspect primary hyperparathyroidism. Which of the following mechanisms is responsible for the patient's current condition?
Increased RANK-L production, dx-Hyperparathyroidism
A 48-year-old female presents to the emergency room with mental status changes. Laboratory analysis of the patient's serum shows: Na+ 122 mEq/L, K+ 3.9 mEq/L, HCO3- 24 mEq/L, BUN 21 mg/dL, Creatinine 0.9 mg/dL, Ca2+ 8.5 mg/dL, Glucose 105 mg/dL. Urinalysis shows: Osmolality 334 mOsm/kg, Na+ 45 mEq/L, Glucose 0 mg/dL. Sputum cytology is shown. A 57-year-old female presents to the emergency department with complaints of nausea, muscle aches, and confusion that presented and worsened over the past several days. On further probing, she also reports a nagging cough with shortness of breath and a 10-lb. weight loss over the last 3 months. She does not have a primary care doctor and denies having regular check ups. She reports smoking 1 pack of cigarettes per day and denies any alcohol consumption. Her medical history is significant for hypertension, a 30 pack year smoking history, and anxiety. Vital signs are as follows: T 37.2 C, HR 86, BP 137/86, RR 14, and SpO2 96%. Physical examination shows normal skin turgor, moist mucus membranes, and no peripheral edema. A CT scan is performed to investigate the patient's cough in Figure A. Lab work is performed in the ED and the findings are below. Na: 128 mEq/L Plasma osmolality: 260 mOsm/kg Urine osmolality: 300 mOsm/kg Urine Na: 47 mEq/L Which of the following is most likely also found in this patient?
Increased antidiuretic hormone, Ddx-SIADH
A 51-year-old female presents to her primary care physician complaining of body aches and constipation. She reports that her "bones hurt" and that she has experienced worsening constipation over the past few months. Her medical history is notable for three kidney stones within the past year that both passed spontaneously. Her vital signs are stable. Physical examination reveals a small nodule near the right inferior pole of the thyroid. Which of the following sets of serum findings is most likely in this patient?
Increased calcium, decreased phosphate, increased parathyroid hormone dx-Primary Hyperparathyroidism
A 56-year-old man is seen in the hospital for a chief complaint of intense thirst and polyuria. His history is significant for recent transsphenoidal resection of a pituitary adenoma. With regard to the man's fluid balance, which of the following would be expected?
Increased extracellular fluid osmolarity, Ddx-Diabetes Insipidus
A 55-year-old man presents to the emergency department because of an excruciating headache that started suddenly after he got home from work. He also reports having double vision. Specifically, in the last week he almost got into two car accidents with vehicles that "came out of nowhere" while he was trying to merge on the highway. Physical examination is notable for ptosis of the left eye, which is also inferiorly and laterally deviated. The patient is treated emergently and then started on a hormone replacement in order to avoid life-threatening post-treatment complications. The patient's current presentation was associated with a pathologic process that existed for several months prior to this event. Which of the following symptoms could this patient have experienced as part of that pre-existing pathology?
Increased hat size-Pituitary Apoplexy
A 28-year-old African American woman presents to her primary care physician with two weeks of nausea, abdominal pain, and increased urination. She states she has had kidney stones in the past and is concerned because her current pain is different in character from what she had experienced then. In addition she reports increasing weakness and fatigue over the past several months as well as mild shortness of breath. Chest radiography shows bilateral hilar adenopathy. Which of the following processes is most likely responsible for her current symptoms?
Increased intestinal absorption of calcium, dx hypercalcemia
A 54-year-old man presents to his primary care physician because of palpitations and diarrhea. He says that the symptoms have been getting worse over time, and he has also felt uncomfortably hot at work. His wife says that she noticed he has become jumpier and that he has been eating more despite losing weight over time. On physical exam, he has hyperactive reflexes and warm and moist skin. A soft painless lump is also felt on the right side of his neck. An imaging study is performed and the result is shown in Figure A. Which of the following is associated with the most likely cause of this patient's symptoms?
Increased malignancy potential with ionizing radiation, Dx- Solitary Thyroid Nodule
A 34-year-old woman presents to her OB/GYN with complaints of missing her last 3 periods as well as intermittent spontaneous milky-white nipple discharge bilaterally for the past 3 months. Vital signs are stable and within normal limits. Neurologic examination is without abnormality, including normal visual fields. Serology and MRI of the brain are ordered, with results pending. Which of the following sets of laboratory results would be expected in this patient?
Increased prolactin, decreased FSH, decreased LH, Ddx Prolactinoma
A 33-year-old female presents to her primary care physician complaining of heat intolerance and difficulty sleeping over a one month period. She also reports that she has lost 10 pounds despite no changes in her diet or exercise pattern. More recently, she has developed occasional unprovoked chest pain and palpitations. Physical examination reveals a nontender, mildly enlarged thyroid gland. Her patellar reflexes are 3+ bilaterally. Her temperature is 99°F (37.2°C), blood pressure is 135/85 mmHg, pulse is 105/min, and respirations are 18/min. Laboratory analysis is notable for decreased TSH. Which of the following pathophysiologic mechanisms contributed to the cardiovascular symptoms seen in this patient?
Increased sensitivity of ß1-adrenergic receptors, Dx- Hyperthyroidism
A 40-year-old female presents to your office complaining of a tender neck and general lethargy. Upon further questioning, she reports decreased appetite, fatigue, constipation, and jaw pain. Her pulse is 60 bpm and her blood pressure is 130/110 mm Hg. Biopsy of her thyroid reveals granulomatous inflammation and multinucleate giant cells surrounding fragmented colloid. Which of the following likely precipitated the patient's condition:
Infection, Dx-Subacute Thyroiditis (de Quervain)
A patient suffering from Graves' disease is given thiocyanate by his physician. Thiocyanate helps in the treatment of Graves' disease by:
Inhibiting iodide follicular uptake, Dx- Gaves Disease
A six-week old male presents with lethargy and hypotonia. On physical exam he is jaundiced and has a large protruding tounge.
Iodine deficiency, Congenital Hypothyroidism (Cretinism)
A 40-year-old woman is found to have a 2-cm right-sided thyroid nodule during a routine physical examination. She has no history of head and neck irradiation or family history of thyroid cancer. The nodule is firm and mobile in relation to the underlying tissue. Vital signs and the remainder of the examination are normal.
Iodine deficiency, Dx Non-Toxic goiter
A 3-month-old boy is brought to the emergency department after his mother found him to be extremely lethargic. He was born at home with no prenatal care and has no documented medical history. On presentation, he is found to have shorter stature and increased weight compared to normal infants as well as coarse facial features. Physical exam reveals a large protruding tongue and an umbilical hernia. The patient otherwise appears normal. Laboratory tests confirm the diagnosis, and the patient is started on appropriate treatment. The physician counsels the parents that despite initiation of treatment, the boy may have lasting mental retardation. Which of the following is most likely associated with the cause of this patient's disorder?
Iodine deficiency, Dx-Congenital Hypothyroidism (Cretinism)
A 27-year-old woman presents with amenorrhea. She had been taking the combined oral contraceptive pill for the last 9 years, stopping this 11 months ago. She is otherwise healthy, but on physical exam she has bilateral galactorrhea. Laboratory work-up reveals an elevated prolactin level of 150 micrograms/L (3000 mIU/L). Normal prolactin levels are up to 25 micrograms/L (500 mIU/L). She also had low-normal gonadotropin (luteinizing hormone
LH
A 45-year-old male presents to the hospital complaining of frequent headaches and a decreased libido. During the physical exam, the patient also states that he has recently been experiencing vision problems. The patient is suffering from what type of adenoma?
Lactotroph-Ddx Prolactinoma
A 38-year-old man presents to the endocrinologist with complaints of increased shoe size and headaches in the morning. These symptoms have developed gradually over the past year but have become especially concerning because he can no longer wear his normal-sized boots. He denies any other symptoms, including visual changes. He was recently started on lisinopril by his primary care physician for high blood pressure. His vital signs are within normal limits and stable. On exam, the endocrinologist notes the findings shown in Figures A and B. These facial features are especially striking when contrasted with his drivers license from 10 years prior, when his jaw was much less prominent. The endocrinologist sends a screening blood test to work-up the likely diagnosis. Which of the following organs or glands produces the molecule being tested in this screening?
Liver- Ddx Gigantism/Acromegaly
A 33-year-old woman presents to her primary care provider for a normal check-up. She reports she has been feeling intermittently fatigued over the past 3 months, but she attributes it to her work as a corporate lawyer and balancing family life. She is otherwise healthy and takes no medications. She was adopted and has no information about her biological family. She has 2 children and has been married for 7 years. She drinks 4-5 glasses of wine per week and does not smoke. Her temperature is 99.2°F (37.3°C), blood pressure is 125/65 mmHg, pulse is 78/min, and respirations are 18/min. On exam, she is well-appearing and in no acute distress. A complete blood count is within normal limits. Additional workup is shown below: Serum: Na+: 139 mEq/L Cl-: 99 mEq/L K+: 3.9 mEq/L HCO3-: 23 mEq/L BUN: 18 mg/dL Glucose: 110 mg/dL Creatinine: 1.1 mg/dL Ca2+: 11.1 mg/dL Parathyroid hormone: 700 pg/mL Urine: Na+: 100 mEq/L/24h Ca2+: 100 mg/24h Osmolality: 400 mOsmol/kg H2O Which of the following is the most likely underlying cause of this patient's condition?
Loss-of-function mutation in the calcium-sensing receptor, dx hypercalcemia(FHH)
A 47-year-old Hispanic male presents with complaints of recent heat intolerance and rapid heart rate. The patient has also experienced unintentional weight loss noting a loss of 15 pounds. Physical exam reveals tachycardia and skin that is warm to the touch. A radioactive iodine uptake scan of the thyroid reveals several focal nodules of increased iodine uptake. The physician orders a serum analysis that will most likely show which of the following?
Low TSH and high T4, Dx- Gaves Disease
A 48-year-old female presents to the emergency room with mental status changes. Laboratory analysis of the patient's serum shows: Na 122 mEq/L K 3.9 mEq/L HCO3 24 mEq/L BUN 21 mg/dL Cr 0.9 mg/dL Ca 8.5 mg/dL Glu 105 mg/dL Urinalysis shows: Osmolality 334 mOsm/kg Na 45 mEq/L Glu 0 mg/dL Which of the following is the most likely diagnosis?
Lung cancer, Ddx-SIADH
A 44-year-old female presents to her primary care physician complaining of fatigue. She reports a four-month history of increasing fatigue accompanied by occasional constipation. She also reports a 15-pound weight gain over the same time period. She is otherwise healthy and takes no medications. She has never been pregnant. On physical examination, her skin is dry and cracked. Patellar reflexes are 1+ bilaterally. Laboratory analysis reveals an elevated serum TSH and decreased serum and free T4. Her blood is positive for the presence of specific antibodies. A biopsy of this patient's thyroid gland would most likely reveal which of the following?
Lymphocytic infiltrate with germinal center formation, Dx-Hashingmoto Throiditis
A 26-year-old African-American woman presents to the clinic for a routine check-up. Review of systems reveals that she often feels nervous and has recently developed a slight tremor. Of note, she has lost 15 pounds in the past 3 months, despite an increased appetite. The patient's temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 85/min, and respirations are 14/min with an oxygen saturation of 98% on room air. On physical exam, her skin is warm and she has mild exophthalmos. Which of the following is the direct mechanism causing the patient's ophthalmologic findings?
Lymphocytic infiltration, Dx- Gaves Disease
A 32-year-old male presents to his primary care physician. The patient has a history of hypertension, which was found to be the result of an adrenal mass. He is status post resection. On physical exam, vital signs are HR 78 bpm, BP 135/90 mmHg, RR 12 rpm, Sat 100%. Examination of the neck reveals a 2 cm firm, immobile, and nontender mass in the right inferior pole of the thyroid. Laboratory evaluation reveals normal TSH, PTH, and calcium. A biopsy of the lesion is obtained, with H&E staining shown in Figure A. What is the most likely diagnosis?
Medullary carcinoma, dx-Thyroid Cancer
A 46-year-old Caucasian female presents with cold intolerance, weight gain, and constipation. She has also noticed that her nails have become thinner recently but denies any fever or neck pain. Which of the following is NOT an expected histological finding in the thyroid?
Multinucleate giant cells-Hashingmoto Disease
A 30-year-old man presents to your clinic complaining of excessive thirst and frequent urination for the past few months. Urine testing reveals a low urine osmolarity, which fails to increase after subjecting the patient to a water deprivation test and injection of desmopressin. Further into the encounter, the patient reveals that he has been on a mood stabilizer for bipolar disorder for several years. Which of the following is the most likely cause of his polyuria?
Nephrogenic diabetes insipidus, Ddx-Diabetes Insipidus
A 28-year-old woman presents with headaches for the past 9 months that have worsened recently. Review of systems is otherwise negative except for some irregularity in her menstruation over the past year. On physical examination she has no stigmata for Cushing syndrome or acromegaly. Her visual fields by confrontation are normal and she has had no galactorrhea.
Nonfunctional pituitary adenoma
A 52-year-old man presents with some difficulty driving at night and reports not seeing cars coming from the sides. He also describes progressive loss of libido and inability to obtain and maintain an erection, which started about 2 years ago. He reports bumping into things. He has gained about 11 lb (5 kg) in weight over the past 2 to 3 years. He has fatigue and is unable to do the same jobs that he used to do a year ago. The examination reveals moderate obesity (BMI 35) with some loss of muscle bulk over the proximal arm and leg muscle groups. Other positive findings include the presence of small bilateral gynecomastia, soft testicles (12 mL), and abnormal visual fields to confrontation, with bitemporal hemianopia.
Nonfunctional pituitary adenoma
Four months after giving birth, a young woman presents to the hospital complaining of lack of breast milk secretion. The patient complains of constantly feeling tired. Physical exam reveals that she is slightly hypotensive and has lost a significant amount of weight since giving birth. The patient states that she has not experienced menstruation since the birth. Which of the following is likely to have contributed to this patient's presentation?
Obstetric hemorrhage Ddx- Sheenhan Syndrome
A 31-year-old woman is 4 months postpartum, breastfeeding, and found to have a resting heart rate of 92 bpm. She has a slightly enlarged non-nodular, nontender thyroid and no proptosis. Serum thyroid-stimulating hormone (TSH) is undetectable, free T4 and T3 are modestly elevated, and thyroid peroxidase antibodies are positive. The ratio of total serum T3 to T4 is 12.
Painless lymphocytic thyroiditis(Hashingmoto Throiditis)
A 62-year-old man presents with atrial fibrillation. He has not noticed any tremulousness, heat intolerance, or weight loss. His thyroid gland is non-nodular, nontender, and slightly enlarged. Serum TSH is undetectable, free T4 and T3 are modestly elevated, and thyroid peroxidase antibodies are positive with a low titer. A 24-hour radioiodine uptake is 0.2%.
Painless lymphocytic thyroiditis(Hashingmoto Throiditis)
A 27-year-old female presents to her physician with a palpable thyroid nodule. Iodine uptake testing shows that the nodule has decreased iodine uptake compared with the rest of the thyroid gland. A fine-needle aspiration is performed and the physician calls telling the patient that she has a neoplasm of the thyroid. Which of the following diagnoses is the most likely?
Papillary carcinoma, dx-Thyroid Cancer
A 43-year-old female presents to her primary care physician complaining of a gradually enlarging neck mass. She reports that she first developed a firm nodular midline mass on the anterior aspect of her neck two months ago. She is otherwise healthy and takes no medications. A fine-needle aspiration is performed and a histological sample of the specimen is shown. Which of the following is the most likely diagnosis?
Papillary thyroid carcinoma, dx-Thyroid Cancer
A 56-year-old male presents to the emergency department with a severe headache that occured suddenly. The patient also complains of not seeing very well. Physical examination is notable for a left-eye ptosis, dilated pupil, that is inferiorly and laterally deviated. A computerized tomography (CT) of the head is performed, which is shown to the right. Neurosurgery was immediately consulted.
Pituitary Apoplexy
A 28-year-old woman presents to her primary care physician complaining of intense thirst and frequent urination for the past 2 weeks. She says that she constantly feels the urge to drink water and is also going to the bathroom to urinate frequently throughout the day and multiple times at night. She was most recently hospitalized 1 month prior to presentation following a motor vehicle accident in which she suffered severe impact to her head. The physician obtains laboratory tests, with the results shown below: Serum: Na+: 149 mEq/L Cl-: 103 mEq/L K+: 3.5 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 105 mg/dL Urine Osm: 250 mOsm/kg The patient's condition is most likely caused by inadequate hormone secretion from which of the following locations?
Posterior pituitary, Ddx-Diabetes Insipidus
A 66-year-old woman presents to her primary care provider with several days of left flank pain radiating to the abdomen and groin. The patient states that she has noticed a pink tinge to her urine as well. Of note, she has not had any fevers, but endorses several months of fatigue and constipation. The patient was previously healthy except for mild untreated hypertension. On exam, her temperature is 98.6°F (37.0°C), blood pressure is 130/84 mmHg, pulse is 76/min, and respirations are 12/min. On further workup, the patient is found to have calcium oxalate nephrolithiasis with hypercalciuria. Blood studies demonstrate increased parathyroid hormone (PTH) and hypercalcemia. Which of the following is the most likely cause?
Primary Hyperparathyroidism
At a routine exam, a 65-year-old woman is discovered to have hypercalcemia. Follow-up laboratory tests show synchronously elevated serum calcium and intact parathyroid hormone, with low phosphorus and mildly elevated alkaline phosphatase. 25-hydroxyvitamin D is in the low normal range. Past medical history is significant for hypertension and coronary artery disease. Review of symptoms includes complaints of fatigue, feeling achy, and vague depression and mental fatigue. The patient has a history of nephrolithiasis and newly detected osteopenia. Family history is negative for renal stones or calcium disorders.
Primary hyperparathyroidism
A 45-year-old white woman presents with symptoms of fatigue, depression, and mild weight gain. Physical exam demonstrates heart rate of 58 beats per minute, coarse dry skin, and bilateral eyelid edema. Serum TSH is 40 milli-international units/L (mIU/L) (normal range, subject to laboratory standards, 0.35 to 6.20 mIU/L), and free T4 is 0.5 nanograms/dL (usual normal range, subject to laboratory standards, is 0.8 to 1.8 nanograms/dL). Therapy is begun with levothyroxine 100 micrograms daily and the patient's symptoms improve. Repeat testing 6 weeks later reveals a normal TSH (5 mIU/L). The patient is maintained on this dose and repeat TSH testing is planned yearly or if symptoms recur.
Primary hypothyroidism-Hashingmoto Disease
) levels. Magnetic resonance imaging (MRI) examination of the pituitary sellar region depicts a 6 mm right-sided pituitary mass, with no suprasellar or parasellar extension.
Prolactinoma
A 45-year-old man presents with loss of libido and some erectile dysfunction. He is otherwise healthy. On physical examination he has mild bilateral gynecomastia and normal testes. Laboratory work-up reveals a highly elevated prolactin level of 2300 micrograms/L (46,000 mIU/L). Normal prolactin levels are up to 15 micrograms/L (300 mIU/L). He also has low testosterone, LH, and FSH levels. MRI exam of the pituitary sella depicts a large 32 mm pituitary macroadenoma with suprasellar extension and optic chiasmal compression. Visual field assessment reveals bitemporal hemianopia.
Prolactinoma
A 35-year-old woman presents to the emergency room with fever, diarrhea, and dysuria for the past day. She also complains of palpitations, poor concentration, and severe anxiety. She was diagnosed with Graves disease 6 months ago but admits that she has missed some doses of her prescribed medications in the past couple of months due to stress. Her temperature is 103°F (39°C) and pulse is 132/minute. A urine culture is obtained and grows Escherichia coli. Which of the following drugs would be most effective in treating this patient's acute condition?
Propanolol, Dx-Thyroid Storm
A 50-year-old obese woman with longstanding, poorly controlled diabetes presents with lethargy and fatigue. Screening labs report that she has a creatinine level of 2.5 mg/dL and a BUN level of 40 mg/dL. Additional labs are ordered, which reveal a calcium level of 7.4 mg/dL and a phosphorus level of 5.9 mg/dL. The parathyroid hormone level is 400 picograms/mL.
Secondary hyperparathyroidism
An 85-year-old female nursing-home patient is being seen for postmenopausal skeletal disease that has become a concern after she fell and broke her wrist. Her bone densitometry reveals osteoporosis (T-score: -3.5). Lab tests return with a calcium level of 8.8 mg/dL and a parathyroid hormone level of 120 picograms/mL. These results prompt vitamin D testing that returns a 25-hydroxyvitamin D level of 14 nanograms/mL.
Secondary hyperparathyroidism
A 65-year-old woman presents to her primary care doctor with progressively worsening headaches over the last few years. She has recently been diagnosed with diabetes mellitus and started metformin a week ago. She has no other significant past medical history and has never smoked. Her husband also reports that her face has changed over the past few months. An earlier photograph of this patient and her current appearance are shown side by side in Figure A. Which of the following would most likely be the best test for diagnosing this patient?
Serum IGF-1 measurement-Ddx Gigantism/Acromegaly A 45-year-old male presents to his primary care physician complaining of increasingly frequent headaches. He also reports that his hats and wedding ring do not fit anymore. His temperature is 99°F (37.2°C), blood pressure is 145/80 mmHg, pulse is 85/min, and respirations are 16/min. Physical examination is notable for frontal bossing, a prominent jaw, and an enlarged tongue. A chest radiograph reveals mild cardiomegaly. Serum insulin-like growth factor 1 levels are significantly elevated. Which of the following conditions is this patient at greatest risk for? [Carpal tunnel syndrome- Ddx Gigantism/Acromegaly
A 34-year-old female presents to her primary care physician complaining of fatigue. Over the last three months she has experienced decreased energy and gained 7 pounds. Review of systems is negative for symptoms of depression but is positive for constipation, myalgias, and cold intolerance. Physical exam is notable for delayed deep tendon reflex relaxation. Vital signs are as follows: T 37.1 C, HR 61, BP 132/88, RR 16, and SpO2 100%. Which of the following is the best initial screening test for this patient?
Serum TSH, Dx-Hypothyroidism
26-year-old woman, 5 days post vaginal delivery, presents to their pediatrician with a complaint that she is unable to breast feed her child. History reveals a vaginal delivery complicated by postpartum hemorrhage.
Sheehan Syndrome
A 75-year-old gentleman is brought to the ED with confusion that started earlier this morning. His family notes that he was complaining of feeling weak last night and also had a slight tremor at the time. He is afebrile and he has no known chronic medical conditions. Physical exam reveals a cooperative but confused gentleman. His mucous membranes are moist, he has no focal neurological deficits, and his skin turgor is within normal limits. His lab results are notable for: Serum Na+: 123 mEq/L Plasma osmolality: 268 mOsm/kg Urine osmolality: 349 mOsm/kg Urine Na+: 47 mEq/L Which of the following malignancies is most likely to be responsible for this patient's presentation?
Small cell lung cancer, Ddx-SIADH
A 32-year-old Caucasian woman presents with a three-month history of weight loss, anxiety, and tremors. She recalls frequent heart palpitations and new discomfort while being outside in the heat. Her labs include a TSH level of 0.1 mIU/L. Additionally, the patient's serum is positive for antibodies that stimulate the TSH receptor. What process is unique to this patient's diagnosis?
Stimulation of retroorbital fibroblasts, Dx- Gaves Disease
A 40-year-old woman with no prior thyroid history presents with 7 days of fevers to 104°F (40°C), shaking chills, myalgias, and pharyngitis. In the last day she has developed a severe neck pain that radiates to her ear and jaw. She noted rapid heartbeat, palpitations, tremor, and feeling hot. The neck pain is severe and has changed from the left side of her neck to the right side in the last 24 hours. She cannot eat or drink anything because it exacerbates the pain. She indicates that the pain is not in her pharynx but over her lower neck and radiates to her ear and jaw. She is mildly distressed and will not let you touch her neck because it hurts so much. On examination, her thyroid is enlarged, firm, and very tender to palpation.
Subacute granulomatous thyroiditis
A 54-year-old female presents to her primary care physician with complaints of fatigue, constipation, and what the patient describes as "aching in her bones." Her medical history is significant for hypertension, well-controlled on lisinopril, and two prior kidney stones that both passed spontaneously without need for surgery. Vital signs are within normal limits, and physical exam is not significant for any notable findings. Preliminary lab work is ordered and reveals: calcium 11.6 mg/dL (normal range 8.5 - 10.9 mg/dL), phosphorus 2.1 mg/dL (normal range 2.4 - 4.1 mg/dL), and an elevated parathyroid hormone (PTH) level. Which of the following findings would most likely be expected on radiographic evaluation of this patient's hands?
Subperiosteal cortical thinning, dx- Primary Hyperparathyroidism
A 34-year-old man presents to his primary care physician with frequent urination. He was recently hospitalized following a severe motorcycle accident in which he suffered multiple injuries to his head and extremities. He reports that he has been constantly thirsty and has been urinating four to five times per night since being discharged from the hospital one week prior to presentation. His past medical history is notable for type II diabetes mellitus, which is well controlled on metformin. He has a 10 pack-year smoking history and drinks 3-4 alcoholic beverages per day. His temperature is 98.8°F (37.1°C), blood pressure is 110/70 mmHg, pulse is 95/min, and respirations are 18/min. Physical examination reveals delayed capillary refill and decreased skin turgor. Notable laboratory results are shown below: Serum: Na+: 148 mEq/L Cl-: 101 mEq/L K+: 3.7 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 110 mg/dL Hemoglobin A1c: 5.7% This patient's condition is most likely caused by defective production in which of the following locations?
Supraoptic nucleus of the hypothalamus, Ddx-Diabetes Insipidus
A 6-year-old boy has had a daily dull headache for the past 6 months. He says that it is a continuous, dull headache that increases a bit every day. He can't focus on playing with friends at school anymore due to the pain. On physical exam, his physician is concerned when the patient's visual field is notably decreased bitemporal. Additionally, physical exam reveals papilledema bilaterally. A stat CT scan is done, revealing suprasellar calcifications.
Surface ectoderm, Ddx- Craniopharyngioma
A 76-year-old homeless white man presents to the emergency department after police find him disoriented on the streets in late August. The patient gives little history, but admits to ongoing cough with productive sputum, night sweats/chills, and mild dyspnea. He proceeds to suffer from a seizure. Vital signs demonstrate an elevated temperature at 101.7°F (38.7°C), a respiration rate of 26 breaths per minute, 94% oxygen saturation (on 3 L of O2), and pulse 87 bpm, with no evidence of orthostatic hypotension. Physical exam demonstrates a malnourished and disheveled man in a postictal state. There is no sign of injury to the body. Crackles can be heard at the right lung base. Lab work demonstrates serum sodium of 120 mEq/L, serum creatinine of 1.0 mg/dL, and negative alcohol and toxicology screens. CXR demonstrates a large infiltrate in the right lower lung, consistent with pulmonary infection or abscess.
Syndrome of inappropriate antidiuretic hormone
A 53-year-old woman presents to the clinic with complaints of fatigue. She reports that over the past several months she has been lethargic and tired. She has gained 10 pounds over the past month but attributes it to her menopause. Her last menstrual period (LMP) was 1 year ago. Past medical history is significant for asthma and seasonal allergies, and medications include a rescue inhaler and cetirizine as need. Review of systems is negative except for cold intolerance and constipation. What is the best next step in evaluating this patient?
TSH levels, Dx-hypothyroidism
A 36-year-old woman complains of severe episodes of headache, tremulousness, palpitations, and anxiety. The patient has noted a change in her voice and she has difficulty swallowing solids. On physical exam, there is a palpable, nontender swelling in the front of her neck that moves with swallowing. There is no cervical lymphadenopathy. Lab studies show hypercalcemia. A radiograph of the cervical region shows irregular calcifications in mass, while an MRI of the abdomen shows confirms the presence of bilateral adrenal lesions.
Thyroid Cancer
A 40-year-old woman is found to have a 2-cm right-sided thyroid nodule during a routine physical examination. She has no history of head and neck irradiation or family history of thyroid cancer. The nodule is firm and mobile in relation to the underlying tissue. Vital signs and the remainder of the examination are normal.
Thyroid Cancer
At a routine checkup, a 70-year-old woman has an irregularly irregular pulse of 88 bpm and BP of 150/60 mmHg. Neck examination reveals an enlarged thyroid (approximately 30 g) with irregular, bumpy texture. There is no substernal extension, lymphadenopathy, or bruit. The remainder of the examination is unremarkable except for a I-II/VI systolic murmur at the left sternal border and minimal tremor of the outstretched hands. The patient denies heat intolerance or nervousness, but says she has lost a few pounds over the past year. There is no history of head and neck irradiation. Her aunt had a goiter.
Toxic multinodular goiter
A 30-year-old woman presents with several months of gradually increasing heat intolerance and nervousness. She has lost 2 to 3 kg. There is no history of head and neck irradiation. She grew up in a mountainous area of Greece and recently immigrated to the US. Her grandmother had a goiter. Physical exam reveals a mildly anxious woman with pulse 90 bpm and BP 140/60 mmHg. There is a 4-cm mobile right-sided thyroid nodule without lymphadenopathy or bruit. She has mild stare and lid lag without exophthalmos; warm moist skin; and a slight tremor. Reflexes are brisk. The remainder of the exam is normal.
Toxic thyroid adenoma
A 44-year-old caucasian male complains of carpopedal spasms, peri-oral numbness, and paresthesias of the hands and feet. His wife also mentions that he had a seizure not too long ago. His past surgical history is significant for total thyroidectomy due to papillary thyroid carcinoma. They then realized all of the symptoms occurred after the surgery. Which of the following would be present in this patient?
hvostek sign, QT prolongation, decreased PTH, decreased serum calcium, increased serum phosphate, Hypoparathyroidism
