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SILLIMAN UNIVERSITY MEDICAL SCHOOL

MEDICINE WORKSHEET
SUBMITTED TO: Walden Usos, M.D DATE OF SUBMISSION: O!o"e# $, %&'(
SUBMITTED BY:
Al)*n +. ,as-.-*n
Ad#*an Re/ A. ,an0o
C0#*s!*an A. ,alo1a#
MEDICINE 2II
RE,RESENTATIVE CASE
Iden!*3/*n4 Da!a: 38 years old, female
So-#e o3 In3o#1a!*on: primary source is from the patiet
C0*e3 Co15l*an!: !ypertesio, fati"ue, ad elar"i" #"ers
MEDICAL HISTORY:
H*s!o#/ o3 ,#esen! Illness: $ 38 year old female, had a history of hypertesio ad ue%plaied
fati"ue for appro%imately &' years( $t that time she had to ha)e her *eddi" ri" cut o+ ,ecause of
elar"i" #"ers( O)er the past year, she has oticed a icrease i shoe si-e from . / to 8 ad a *ei"ht
icrease from &3'0&.' pouds( Mestruatio had also stopped( There *as persistet um,ess ad
ti"li" i her hads, icrease ace ad e%cessi)e sori" at i"ht(
,AST MEDICAL HISTORY: !ypertesio
FAMILY HISTORY: 1oe pro)ided
,ERSONAL AND SOCIAL HISTORY: 1oe pro)ided
,HYSICAL E6AMINATION and REVIEW OF SYSTEMS
,HYSICAL E6AMINATION
+ene#al: $ *ell appeari" *oma
V*!al S*4ns:
B2 3 &4'56' mm!"
!7 3 84 ,pm
9ei"ht 3 &.' :,
!ei"ht: 4;3 feet
S7*n: multiple s<i ta"s
HEENT: *ide spaced teeth, thic<ei" of her asola,ial folds, ad frotal ,ossi", thyroid *as palpa,le
ad di+usely elar"ed(
+UT: o hirsutism or )irili-atio
E8!#e1*!*es: acral cha"es *ith =eshy hads ad feet
REVIEW OF SYSTEMS
>?@ *ei"ht "ai
>?@ *ea<ess ad fati"ue
>?@ ameorrhea
>?@ um,ess
>?@ ace
>?@ e%cessi)e sori"
,RIMARY WORKIN+
IM,RESSION
RULE IN RULE OUT
A#o1e4al/ Seonda#/ !o
An!e#*o# ,*!-*!a#/
Ma#oadeno1a 9*!0
H/5e#!ens*on,
D/sl*5*dae1*a, and
D*a"e!es T/5e %
H8: !ypertesio, fati"ue, elar"i"
#"ers ad feet, *ei"ht "ai,
ameorrhea, persistet ti"li" i
hads, icreased ace, icreased
sori"
,E: icreased *ei"ht, multiple s<i
ta"s, *ide spaced teeth, thic<ei" of
asola,ial folds, frotal ,ossi"(
Aaot ,e ruled out
LABS:
Icreased BBS, icreased tri"lyceride,
:D:, ad decreased !D:, icreased
!,$&c, icreased OCTT, Icreased ICB
I, icreased serum prl(
I1a4*n4: %ray result sho*s a
elar"i" sella turcica, M7I results
sho*s a pituitary tumor &(D cm i
si-e(
DIFFERENTIAL DIA+NOSIS RULE IN RULE OUT
MC-ne:Al"#*40!
s/nd#o1e
H8: Ele)ated ,lood pressure,
ameorrhea, thic<ei" of asola,ial
folds ad frotal ,ossi"
,.E: deformities i the ,oe of the face
La"s: icreased ,lood prolacti
>0@ cafE au lait pi"metatio
>0@ 2olyostotic #,rous dysplasia
>0@ arrhythmias
>0@ :i)er disease
Fa1*l*al A#o1e4al/
H8: Elar"i" #"ers, *ei"ht "ai,
ameorrhea
,.E: : *ide spaced teeth, thic<ei" of
her asola,ial folds, ad frotal
,ossi", acral cha"i"
>0@ family history of acrome"aly
Ca#ne/ S/nd#o1e
H8: fati"ue, hypertesio, ameorrhea,
,E: *ide spaced teeth, thic<ei" of
her asola,ial folds, ad frotal
,ossi", acral cha"i"
>0@ $trial my%omas
>0@ fra"ile ad thi s<i
>0@ stretch mar<s
>0@ e%cessi)e hair "ro*th
l
M-l!*5le Endo#*ne
Neo5las*a : '
H8: Bati"ue, ameorrhea, hypertesio
,E: *ide spaced teeth, thic<ei" of
her asola,ial folds, ad frotal
,ossi", acral cha"i"
LABS: icreased serum prolacti, ICB I,
BBS, OCTT, !,$&c(
I1a4*n4: M7I results sho*s a
pituitary tumor &(D cm i si-e(
>0@ a,domial pai
>0@ a%iety
>0@ *ei"ht loss
>0@ metal cha"es
>0@ muscle pai
>0@ loss of appetite
>0@ sesiti)ity to cold
>0@ ausea ad )omiti"
>0@ )isio pro,lems
C-s0*n4 s/nd#o1e
H8: hypertesio ad *ea<ess,
icrease i *ei"ht, ace, fati"ue,
ameorrhea
,E: hei"ht: 4;3F, *ei"ht: &.' l,, B2:
&4'56', mar<edly cha"ed facial
features
>0@ hirsutism
>0@ purple striae
>0@ *ide0spaced teeth
>0@ palpa,le ad di+usely
elar"ed thyroid
TEST NORMAL
VALUES
,ATIEN
T;S
RESULT
S
NECESSITY<INTER,RETATION AVAILABI
LITY
COST
=,H,
>
Fas!*n4
Blood
S-4a#
&'&0&D4
m"5dl
&4.
m"5dl
Basti" ,lood "lucose: $ test to determie
ho* much "lucose >su"ar@ is i a ,lood
sample after a o)eri"ht fast( The fasti"
,lood "lucose test is commoly used to
detect dia,etes mellitus( $ ,lood sample is
ta<e i a la,, physiciaGs oHce, or hospital(
The test is doe i the mori", ,efore the
perso has eate(
The patiet has a icreased result( The
SUMA,
!A!,
1O2!
patiet may ,e dia,etic(
L*5*d
,#o?le
T#*4l/e#*de
s
Lo9
Dens*!/
L*5o5#o!e*n
H*40
Dens*!/
L*5o5#o!e*n
I &4'
m"5dl
I&''m"5dl
4'0 46m"5dl
&84
m"5dl
D&'
m"5dl
3J m"5
dl
The lipid pro#le is total cholesterol ,ro<e
do* to its compoets: !D:, :D:, ad
tri"lycerides >TC for short@( The lipid pro#le
is oe predictor of ris< for heart disease(
The :D:, TC are icreased ad the !D: is
decreased the patiet has dyslipidaemia(
SUMA,
!A!,
1O2!
TSH
(3J0J(D4
mlu5:
'(J.
mlU5l
$ TS! test is a la, test that measures the
amout of thyroid stimulati" hormoe
>TS!@ i your ,lood( TS! is produced ,y the
pituitary "lad( It tells the thyroid "lad to
ma<e ad release thyroid hormoes ito the
,lood(
TS! is ormal
SUMA,
!A!,
1O2!
F#ee T@
'(8'0&(J8
mlU5:
'(D&
mlU5:
This thyroid fuctio ,lood test measures
the amout of thyro%ie, or TJ, i the ,lood(
The free TJ is decreased ,ecause of less
productio of TJ(
SUMA,
!A!,
1O2!
H"A' J0. K
8('
m"5dl
The hemo"lo,i $&A test is a )alua,le
measure of the o)erall e+ecti)eess of
,lood "lucose cotrol o)er a period of time(
This is usually measured e)ery D to 3
moths( The <ey )alue is the perceta"e of
hemo"lo,i i red ,lood cells that is coated
i su"ar(
The patiet has a icreased result( The
patiet may ,e dia,etic
SUMA,
!A!,
1O2!
'&& 4#a1s
O+TT
I Du"5 :
Baselie
C! &8
u"5:
C! after
.' mis
&' U"5:
C! after
&D'
mis 4
u"5:
The oral "lucose tolerace test >OCTT@
measures the ,odyGs a,ility to use a type of
su"ar 0 "lucose, that is the ,odyGs mai
source of eer"y( $ OCTT ca ,e used to
dia"ose predia,etes ad dia,etes(
The patiet has a icreased result( The
patiet has dia,etes(
SUMA,
!A!,
1O2!
I+F:I &&60D'J
"5ml
33'
"5ml
ICB0& is measured to help dia"ose the
cause of "ro*th a,ormalities, e)aluate
pituitary fuctio, ad moitor treatmet of
C! de#ciecies ad e%cesses(
SUMA,
!A!,
1O2!
The ICB I is icreased( The patiet has a
icreased5 e%cess "ro*th hormoe
secretio
Se#-1 ,RL
&(60D3
"5ml
3D
"5ml
2rolacti >also called 27: or lacto"eic
hormoe@ is a hormoe produced ,y the
pituitary "lad i the ,rai( 2rolacti plays
a importat role i the reproducti)e health
of ,oth *ome ad me( Its mai role,
ho*e)er, is to stimulate the productio of
mil< i *ome after child,irth( I other
*ords, prolacti tri""ers lactatio( The
speci#c fuctio of prolacti i me is ot
*ell <o*, althou"h le)els of prolacti
ha)e ,ee foud to ,e a measure of se%ual
satisfactio i ,oth me ad *ome(
$ prolacti test is a ,lood test that
measures the le)el of the hormoe i your
,ody(
There is a icreased result( The patiet
may ha)e a tumor
I the pituitary "lad(
SUMA,
!A!,
1O2!
' 14
De8a1e!0a
sone
S-55#ess*o
n Tes!
D03u"5dl J u"5dl
This test i)ol)es ta<i" a dose of a
corticosteroid medicie called
de%amethasoe to see ho* it a+ects the
le)el of a hormoe called cortisol i the
,lood( This test screes for Aushi"Gs
sydrome, a coditio i *hich e%cess
amouts of cortisol are ,ei" produced ,y
the adreal "lads( 1ormally, *he the
pituitary "lads ma<e less $AT!, the
adreal "lads ma<e less cortisol(
De%amethasoe, *hich is li<e cortisol,
decreases the amout of $AT! released ,y
the pituitary "lad, *hich i tur decreases
the amout of cortisol released ,y the
adreal "lads(
7esult i icoclusi)e( May eed retesti"(
SUMA,
!A!,
1O2!
I1a4*n4
Tes! No#1al
Ran4e
,a!*en!A
s Res-l!
In!e#5#e!a!*on<Neess*!/ A)a*la"*l*
!/
Cos!s
S7-ll 6:#a/ Uremar<a,l
e
Elar"e
met of
the sella
turcica
The s<ull %0ray remais i)alua,le as a #rst
step i the dia"osis of may edocrie
disorders( 2ituitary tumors commoly
cause elar"emet or distortio of the
sella turcica, *hich ca ,e see o s<ull %0
ray( 2iealomas ad craiophary"iomas
may also ,e detected(
!yperparathyroidism ca cause "raular
decalci#catio i the s<ull(
!ypoparathyroidism produces calci#catio
of the ,asal "a"lia ad cere,ellum(
:esios due due to metastatic
mali"acies or eosiophilic "raulomas
may ,e oted i cases of dia,etes
SUMA,
!A!,
1O2!
isipidus( Sellar elar"emet may ,e due
to the Lempty sellaL sydrome( T*ety0#)e
percet of all cases of elar"ed sella may
,e accouted for ,y this sydrome(
The result sho*ed a elar"emet of the
sella turcica( The patiet has a tumor i
the pituitary "lad(
MRI o3
,*!-*!a#/
+land
Uremar<a,l
e
'.% 1
1ass
M7I scas are freMuetly used to e)aluate
the iteral structures of the ,rai(
2ituitary "lad M7Is are used to disco)er
tumors of the pituitary "lad( $ pituitary
M7I is also sometimes called a sella M7I(
The result sho*s a tumor i the pituitary
"lad(
SUMA,
!A!,
1O2!
FINAL DIA+NOSIS: A#o1e4al/ Seonda#/ !o An!e#*o# ,*!-*!a#/ Ma#oadeno1a 9*!0
H/5e#!ens*on, D/sl*5*dae1*a, and D*a"e!es T/5e %
THERA,EUTICS
A. LIST OF ,ROBLEMS B. THERA,EUTIC OBBECTIVES
&( 2ituitary mass5
macroadeoma
D( Elar"i" #"ers
3( Bati"ue
J( 9ei"ht "ai
4( !ypertesio
.( !yper"lycemia
8( Dyslipidemia
8( Aetral
hypothyroidism
6( $meorrhea
&'( 1um,ess ad
ti"li"
&&( Icreased ace
&D( E%cessi)e sori"
&3( Sleep apea
&( 7elie)e *ea<ess ad impro)e acti)ity tolerace
D( 7elie)e hypertesio ad maitai ,lood pressure *ithi ormal
limits
3( :o*er do* ,lood "lucose le)els
J( Decrease :D:, T$C ad icrease !D:
4( Treat uderlyi" disease
.( Aotrol hormoal im,alace
8( 7estore ormal mestrual cycle
8( 2re)et further *ei"ht "ai
6( Decrease ace, e%cessi)e sori", um,ess ad ti"li"
&'( 7elie)e other associated symptoms of the disease
&&( Esure patiet;s safety
MANA+EMENT
Ad)*e And In3o#1a!*on Non:,0a#1aolo4* Mana4e1en!
Iform the patiet of her disease ad its
symptomatolo"y, ris< factors ad pro"oses(
Tell the patiet to "et proper utritio throu"h
a *ell0,alaced diet(
E%ercise for at least &4' miutes per *ee<
$d)ice the patiet to cosult *ith the doctor
or a re"istered dietitia for ad)ise o the diet(
Iform the patiet to ,e*are of too much
sodium ,ecause it ca a+ect the ,lood
pressure, cause s*elli", ad "ai *ei"ht(
Stress the importace of tryi" to <eep the
cholesterol i chec<
$d)ice the patiet to limit the ita<e of fatty
foods ad eat dairy products >such as mil<
ad cheese@ that are lo* i fat(
Emphasi-e the eed for ta<i" medicatios as
directed(
Stress the importace of social ad
7efer to eurosur"eo for a traspheoidal
hypophysectomy
2ut patiet to ,ed rest(
Ci)e a OD supplemet N D:5mi to pro)ide
adeMuate o%y"eatio
Start IO lie of 21SS N 3' "tts5mi
Moitor ita<e ad output of the patiet
Moitor )ital si"s e)ery J hours
Esure patiet safety
S-#4*al ,#oed-#e:
Trasspheoidal sur"ical resectio
,os!:o5e#a!*)e a#e
Daily sur"ical *oud care
Oital si" e)ery D hours util sta,le
Ecoura"e early am,ulatio
psycholo"ical support duri" treatmet ad
duri" the le"th of disease(
I)ol)e the family ad lo)ed oes i
treatmet ad educate them o the
importace of pro)idi" emotioal support to
the patiet(
Stress the importace of re"ular chec< ups
$d)ice patiet to see< medical help for ay
pro,lems arisi", may it ,e from the
treatmet or ot, or ay other cocers the
patiet may ha)e(
2ro)ide e)iromet suita,le for rela%atio
O+er emotioal support
,HARMACOLO+IC MANA+EMENT
D#-4 Na1e ECa/ Sa3e!/ S-*!a"*l*!
/
Cos!
So1a!os!a!*n Analo4-e
Octreotide
>Sadostati@
Decreases C! ad
ICB0& secretioP
supresses :!
respose to C7!
secretio ad
decreses
splachic ,lood
=o*
Con!#a*nd*a!*on
!ypersesiti)ity
Ca-!*on
!epatic or real
impairmet may
ecessitate dosi"
adQustmets, alter fat
a,sorptio, decrease
)it B&D le)els,
moitor for
hypothyroidism, AOD,
ehace to%icity of
RTc0prolo"i"
a"ets, may icrease
fertility
$crome"aly, relief
of edocrie
tumors,
pre)etio of
complicatio
follo*i"
pacreatic
sur"ery
$mp '(&m"5ml
>263J(.4@
'(4m"5ml
>2J'.4('&@
+#o9!0 Ho#1one Ree5!o# An!a4on*s!
2e")isomat
>Soma)ert@
7ecom,iat
"ro*th hormoe
ata"oist
Con!#a*nd*a!*on
!ypersesiti)ity
Ca-!*on
2otetial for C!
de#ciecy,
lipohypertrophy, may
icrease li)er fuctio
test
$crome"aly Oial &'m"
>2JJ6.(J3@
&4m"
>2.8J4(4&@
D'm"
>28663(8D@
Do5a1*ne Ree5!o# A4on*s!
Aa,er"olie
>Dostie%@
Dopamie receptor
a"oist *ith hi"h
aHity for DD
receptors, there,y
ihi,iti" prolacti
release
Con!#a*nd*a!*on
Ucotrolled !21,
hypersesiti)ity,
se)ere hepatic dse,
se)ere pre0eclampsia,
history of AOD
Ca-!*on
Iitial dose of S&m"
may produce
orthostatic !21,
cocomitat
hypertesi)es, ca
cause cardiac
dama"e, ihi,its
lactatio
Treatmet of
hyperprolactiemi
a, either
idiopathic or
pituitary adeoma
Ta, '(4m"
>2&.&3(84@
An!*:D*a"e!* D#-4s
Metformi
>Diafat@
Decreases hepatic
"ucose productioP
decreases CI
"lucose a,sorptioP
Con!#a*nd*a!*on
!ypersesiti)ity, A!B,
meta,olic acidosis,
DT$, 7eal dse,
Maturity0oset
DM( $dQu)at
therapy to IDDM
patiets *ho are
Ta, 4''m" % .'Gs
>23&&(44@
84'm" % .'Gs
icreases tar"et
cell isuli
sesiti)ity
lactatio
Ca-!*on
Dehydratio,
de,ilitatio,
malutritio, hea)y
alcohol use, hypo%ic
states, hepatic
impairmet, ifectio0
iduced stress, fe)er,
trauma, sur"ery,
elderly
usually o,ese ad
ot *ell0cotrolled
*ith isuli
>2.44(6'@
Clipi-ide
>Miidia, OD@
Icrease ,eta
isuli secretioP
may also decrease
rate of hepatic
"lucose productio,
ad icrease
isuli receptor
sesiti)ity
Con!#a*nd*a!*on
!ypersesiti)ity, DM
type &
Ca-!*on
Use *ith cautio o
patiets *ith ris< of
se)ere hypo"lycemia,
pre"acy ad
lactatio
$dQuct to diet i
DM type D
Ta, 4m"
>2D3(36@
&'m"
>2D6(D3@
7osi"lita-oe
maleate
>$)adia@
Impro)e tar"et cell
respose to isuli
*ithout icreasi"
pacreatic cell
secretioP acti)ates
uclear pero%isome
proliferator0
acti)ated receptor
"amma, *hich
i=ueces the
productio of "ee
products i)ol)ed
i "lucose ad lipid
meta,olism(
Con!#a*nd*a!*on
!ypersesiti)ity, DT$,
!B, acti)e li)er
disease
Ca-!*on
Icreased ris< for
A!B, DM type &,
edema, ris< of
hypo"lycemia
Used i
com,iatio *ith
metformi or
sulfoylurea
Bilm0coated tilta,
Jm" % D8Gs
>2&8'8(''@
Jm" % 4.Gs
>23.&J(''@
8m" % D8Gs
>2D88D(''@
An4*o!ens*n Ree5!o# Blo7e#
:osarta
>Ao-aar@
Bloc< ,idi" of
a"iotesi II to
type & a"iotesi
II receptorsP ,loc<s
the )asocostrictor
ad aldosteroe0
secreti" e+ects of
a"iotesi II
Con!#a*nd*a!*on
!ypersesiti)ity, do
ot coadmiister *ith
alis<ire
Ca-!*on
$"ioedema, )olume0
depletio, se)ere
A!B, hepatic or real
impairmet, ris< of
hypotesio,
hyper<alemia
!21 ad real
protectio i type
D dia,etic patiets
*ith proteiuria(
7eductio i the
ris< of AO
mor,idity ad
mortality i
hypertesi)e
patiets *ith left
)etricular
hypertrophy
Ta, 4'm"
>2J'(JD@
&''m"
>2J8(JJ@
T0*aD*de D*-#e!*s
!ydrocholorothia-i Ihi,its 1a
rea,sorptio i
Con!#a*nd*a!*on
!ypersesiti)ity,
Essetial !21 Ta, J'm"5&D(4m"
>2JJ(86@
de >Micardis 2lus@ distal real tu,ulesP
results i icreased
e%cretio of 1a
?

ad *ater, also T
?

ad !
?
ios
auria
Ca-!*on
DM, =uid or
electrolyte im,alace,
hyperuricemia or
"out, hypotesio,
S:E,li)er or real dse,
a""ra)ate di"italis
to%icity, sesiti)ity
reactios may occur
*ith or *ithout
history of aller"y,
male se%ual
dysfuctio, acute
trasiet myopia
8'm"5&D(4
m"
>288(.8@
L*5*d:Lo9e#*n4 A4en!s
Sim)astati
>Uocor@
!MC0Ao$
reductase ihi,itor,
ihi,its the rate0
limiti" step i
cholesterol
,iosythesis ,y
competeti)ely
ihi,iti" !MC0Ao$
reductase
Con!#a*nd*a!*on
!ypersesiti)ity, acti)e
li)er disease,
pre"acy, lactatio,
stro" AY23$J
ihi,itor
Ca-!*on
1o0serious ad
re)ersi,le co"iti)e
SE may occur,
icreased ,lood su"ar
ad !,$&c reported,
hea)y alcohol use, h%
of li)er disease, real
failure, se)ere
electrolyte ad
edocrie or
meta,olic disorders,
ris< for myopathy(
A!D,
hyperlipidemia,
homo-y"ous
familial
hypercholesterole
mia
Ta, &'m"
>236(D8@
D'm"
>236(D8@
J'm"
>236(D8@
8'm"
>236(D8@
Beo#,rate
>:o#,ra@
Icreases O:D:
cata,olism ,y
ehaci"
sythesis of
lipoprotei lipase,
resulti" i
decrease TC ,y 3'0
.'KP !D: may
icrease
Con!#a*nd*a!*on
!ypersesiti)ity,
se)ere li)er5real dse,
primary ,iliary
cirrhosis, pre0e%isti"
"all,ladder disease
Ca-!*on
Aholethiasis, myal"ia,
pacreatitis,
cholecystitis, 2UD
Treatmet of adult
patiet *ith )ery
hi"h ele)atios of
serum TC le)els
ad *ho do ot
respod
adeMuatley to diet
ad other
appropriate
measures
Aap D''m"
>2DD(''@
Bish Oil
>1atureGs Aare
Bish Oil@
Ihi,its platelet
a""re"atioP
decrease
productio of
i=ammatory
prosta"ladis
Con!#a*nd*a!*on
Dia,etes,
immuode#ciecy
Ca-!*on
$spiri sesiti)ity,
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