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Flashcards in The Patients Deck (24)
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1
Q

A pt presents with weakness, fatigue, depression, bradycardia, skin/nail changes, and cold intolerance. She has also noticed some weight gain and says her periods seem heavier. You perform a physical exam and note that it takes a few seconds for her limbs to relax back to a resting position after a DTR is activated. What do you suspect? What lab values might you see? What is your first line treatment?

A

Hypothyroidism. Lab values should show either elevated TSH with decreased T4 (primary) or decreased T4 as well as decreased TSH (secondary). You will likely start this patient on Levothyroxine therapy.

2
Q

A pt presents with a multi-nodular and enlarged goiter. TSH and T4 levels are normal. They originate from a country with high sorghum, millet, maize, and cassava consumption. She reports no serious symptoms but states that since she’s been pregnant, it seems to be getting bigger and is beginning to make it difficult to swallow. What do you suspect?

A

Endemic goiter

3
Q

A pt who is recovering from mono suddenly presents with marked delirium, severe tachycardia, N/V, diarrhea, and associated dehydration. When his temperature is taken, he is found to be 104 decrees F. What do you suspect? What drug/s should be administered? What drug should be avoided?

A

Thyroid “Storm”. He should be given propanolol, a thiourea (methimazole) medication, and likely hydrocortisone. ASA should be avoided.

4
Q

A 30yo female pt presents with a goiter and obvious exopthalmos and tremors. ANA as well as TSI levels are elevated. She complains of sweating, weight loss, anxiety, palpitations, loose stools, and says “she can’t take the heat” like she used to. Her period has become irregular and she is noticing that she feels jittery. What do you suspect? What is most common disease associated with it? How will you treat her?

A

Hyperthyroidism. Graves disease is the most common cause. Prescribe propanolol and possibly a thiourea (methimazole) medication.

5
Q

A 25yo female pt presents with a diffusely large, firm, and finely nodular thyroid. She is complaining of dry eyes and mouth and states she has previously been diagnosed with sjogren syndrome. She is also complaining of weakness, fatigue, GI changes, heavier periods, skin and nail changes. She also feels like she can never seem to get warm. You note that her antithyroperoxidase levels are increased. What do you suspect? How common is it? What would worry you if one side of her thyroid gland were more enlarged than the other? How will you treat her? Will you perform any procedures?

A

Hashimoto thyroiditis. It is the most common thyroid disorder in the US. If one side of her thyroid were larger than the other, you would worry about neoplasm. A fine-needle-aspiration biopsy may be performed. Medication should include Levothyroxine.

6
Q

An elderly woman with a known history of thyroid disorder who recently suffered a stroke suddenly presents with sudden impaired cognition and confusion. She is found to be hypothermic, hypoglycemic, hyponatremic, hypotensive, and does not appear to be breathing fast enough. What do you suspect? Is it a medical emergency?

A

Myxedema crisis. It is a life threatening manifestation of hypothyroid.

7
Q

A pt presents for a routine physical and is found to have some small nodules on the surface of her thyroid. Her thyroid levels are normal. What do you want to do? What do you suspect? What would you consider?

A

Ultrasound and thyroid function tests. Likely benign thyroid nodules. 10% of thyroid adenomas are malignant. Take precautions and check.

8
Q

A pt who recently suffered from a viral infection presents with a painful, enlarged thyroid that is making it difficult for him to swallow. The pain is also radiating into his ears. He does have a low-grade fever and just doesn’t feel good. He is fatigued and just can’t seem to figure out what’s going on. His ESR is highly elevated and his RAI is low. What do you suspect? What drug will you give him?

A

Subacute thyroiditis. ASA is the drug of choice.

9
Q

An elderly man presents with and enlarged thyroid gland that contains small rounded growths. He appears to have symptoms associated with hyperthyroid as well. What do you suspect? What will you give? What might you ultimately have to do?

A

Toxic multi-nodular goiter. Propanolol and methimazole should be given, however surgery is the definitive treatment.

10
Q

A pt presents with painless, firm, swelling of the thyroid region. She is euthyroid but admits to having had irradiation of the head and neck in her past when she and her friends used to gather in the X-ray room snapping seedy pictures of each others faces. What do you suspect? What is the likely cause? What will you likely do…just to be safe?

A

Thyroid cancer. Papillary carcinoma’s are the most common type of cancer in this area. You will likely perform a thyroidectomy to attempt to get the whole cancer before someone gets hurt.

11
Q

A 70yo male british pt presents with bone pain, kyphosis, and bowed tibias. The pt claims his hats don’t fit him any more and he’s having a hard time hearing his wife when she speaks to him. He also states he’s been having headaches more often. He has been hospitalized a lot lately for fractures from “silly things” that he didn’t think would injure him. The pt is found to have dense, expanded bone on radiograph with what appear to be multiple fissure fractures in his femurs and tibias. He suddenly remembers that his dad and brother had something similar happen to them as well that seemed to get worse through the years. Labs show an elevation in serum alk phos. What might this be? Since he is symptomatic, what medication/s would you consider?

A

Paget’s disease of the bone. Biphosphonates are the drugs of choice for these patients.

12
Q

A female pt presents with a history of multiple fractures with a specific propensity to fracture her spine, hips, pelvis, and wrists. It seems to be getting worse with age. She has taken high-dose corticosteroids for as long as she can recall. What could this be? How can you prevent it from happening?

A

Osteoporosis. It can be prevented by improving dietary habits to include higher protein, calcium, Vit D, and overall caloric consumption. Avoiding corticosteroid use is also a valuable preventative measure. Staying active will help prevent its onset as well as avoiding smoking and alcohol.

13
Q

A female pt presents to clinic with blue sclerae, dental abnormalities, and hearing loss. What on earth causes a freakin blue sclerae???

A

Osteogenesis imperfecta

14
Q

A pt presents with pelvic girdle bone pain and tenderness. In children, his disorder is associated with rickets and similar findings might be found on radiology. This pt has hyperparathyroidism. What are you leaning towards? What might this patients urine and serum calcium levels look like? Serum vitamin D? Alk phos?

A

Osteomalacia. This pt will have low urine calcium, low serum calcium, low serum Vit D, and decreased alk phos.

15
Q

A pt presents with presents with fatigue, muscle weakness, and says she had a hard time pulling herself out of the bathtub. She states that she has noticed increased acne, striae around the thigh area and abdomen, and bruising. She says she has noticed her body “changing” in that she feels she is getting fat around the mid-section and she has noticed some fat developing around her clavicle and at the base of her neck. What do you suspect? What initial test would you want to perform? How would you treat it?

A

Cushing’s syndrome. A dexamethasone suppression test should be performed. Surgical resection of the pituitary adenoma may be necessary as well as steroid replacement therapy to follow.

16
Q

A pt suddenly presents with confusion, weakness, abdominal pain, N/V, diarrhea, a fever of 40.6C, and significant hypotension. The pt is known to have addison’s disease and is currently being treated for that but has recently suffered a significant illness. What might this be? How will you know? What will you treat them with immediately?

A

Acute adrenal insufficiency. Eosinophils may be elevated. You may also see markedly elevated ACTH. Treat with hydrocortisone ASAP.

17
Q

A young pt from a developing country who is known to have TB suddenly presents with increasing weakness, fatigue, weight loss, anorexia, N/V, emotional changes and a strange darkening of his skin pigmentation. He states his pubic hair and axillary hair seems to be thinning. He states that sometimes he feels lightheaded. What do you suspect? How will you know? How will you treat it?

A

Chronic adrenocortical insufficiency (addison’s disease). You will likely find low cortisol levels and elevated ACTH levels. These pts also are commonly hypoglycemic, hyponatremic, and hyperkalemic. Treat them with hydrocortisone.

18
Q

A female pt presents with some serious concerns. She states she is “growing a beard” and feels like her acne is worse than when she was a teenager. Her period has been irregular for a few months. She says she is losing her hair, feels like her voice is getting deeper, and that her breasts are shrinking. What might this be? What causes it?

A

Hirsuitism/Virilization. Excess androgen levels can cause this in women as well as polycystic ovarian syndrome, acromegaly, and ACTH induced cushing’s disease.

19
Q

A pt presents with severe HTN, muscle weakness, paresthesias, tetany, polydipsia, polyuria and associated hypokalemia. What do you suspect? How common is it? What are some possible causes? How would you treat it?

A

Primary hyperaldosteronism. It is the most common cause of refractory HTN in youth and middle-aged adults. It can be caused by Conn syndrome (aldosterone producing adrenal adenoma) or adrenal hyperplasia. Treatment should include spironolactone/eplerenone (K+ sparing diuretic).

20
Q

A pt presents complaining of multiple attacks of headaches, sweating, palpitations, and anxiety. She states the doctors stated that she had paroxysmal HTN during her last surgery. She is found to have a normal T4 and TSH but her urine catecholamines were elevated. She states she feels like she’s always excited. What could this be? What’s the best test for it? What’s the treatment of choice for it?

A

Pheochromocytoma. The plasma fractionated free metanephrines is the single most sensitive test. The treatment of choice is surgical removal.

21
Q
BONUS ROUND: 
A: Secondary adrenal insufficiency - treat with…
B: Hypothyroidism - treat with…
C: Hypogonadism - treat with…
D: GH deficiency - treat with…
E: Hyperprolactinemia - treat with…
F: Hypopituitarism - treat with...
A
A: Hydrocortisone 15-35mg
B: Levothyroxine
C: Estrogen replacement (women)   Testosterone replacement (men)
D: Sub-Q recombinant HGH, IGF-I
E: Dopamine agonist
F: Bromocriptine (to treat tumor)
22
Q

A pt presents with unrelenting thirst for water. However, he denies being dehydrated because he is constantly pissing. What might this be? What is low in these patients? What can cause it? What do you expect is Na+ concentration to be?

A

Diabetes insipidus. ADH is very low in these patients so they cannot maintain their water levels and will be constantly thirsty. It can be familial or idiopathic, or could be caused by injury to the hypothalamus or pituitary stalk. This pt will be dehydrated and will be hypernatremic.

23
Q

A hospitalized pt who suffered a basilar skull fracture presents with lethargy, weakness, confusion, and just had a seizure. She is found to have significant hyponatremia. What do you suspect? How would you treat it?

A

SIADH. You would want to administer a hypertonic solution to increase Na+ levels.

24
Q

A male patient presents with infertility, decreased sex drive, and an inability to achieve erection. He suffers from a psychotic disorder and commonly takes large doses of haldol (haloperidol). He is also noticing that he appears to be sprouting boobies. What could this be? How would you treat it?

A

Hyperprolactinemia. He should receive a dopamine agonist and perhaps not take any more of his haloperidol until his medical status stabilizes.