New pathphys case

Published

Specializes in student; help!.

Okay kids, here's the latest case study:

A 23-year-old college student goes to her doctor complaining of headache, fatigue, weight gain and a nagging cough. She is normally very active, competing in volleyball, soccer and rugby. She's achy and always feels like she has a chill. She says she has been trying to lose the weight by exercising more and eating lots less, but it doesn't seems to be helping. All that is happening is she can hardly drag herself out of bed. And her hands and joints are swollen. After checking for joint damage (there is none) her doctor sends her along to an endocrinologist who orders a series of tests and gets the following results.

She has elevated TSH (15 mcg/ml), low free t4 (0.05 ng/dl), elevated calcitonin (18 pg/ml) and elevated growth hormone (8 ng/dl).

They did a fasting OGTT but that seems normal (though if anyone can point us to a site that lists ranges of a 30-minute serum level, we'd probably be willing to deify you).

We're wavering on this one. We're leaning toward hypothyroidism, but not sure if it's Hashimoto or not, and if it is, how the growth hormone and calcitonin fit into the picture. We've been at it for about 2 hours today and are going to take a break for now. But have fun with it. It's due the 25th and I expect to get grades within a week after.

Up Vote Up Vote ×
Specializes in Maternal - Child Health.

http://www.ncbi.nlm.nih.gov/pubmed/6516695

Elevated serum calcitonin levels in patients with thyroid disorders.

Up Vote Up Vote ×
Specializes in Maternal - Child Health.

http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/003706.htm

GH is released in pulses, so a higher level may be normal if the blood was drawn during a pulse.

High levels of growth hormone may indicate:

* Acromegaly

* Gigantism

* Growth hormone resistance

* Pituitary tumor

Up Vote Up Vote ×

in order to differentiate between hypothyroidism and hashimoto's:

"the presence of thyroid autoantibodies, typically anti-tpo and also anti-tg antibodies, delineates the cause of hypothyroidism as hashimoto thyroiditis or its variant. however, 10-15% of patients with hashimoto thyroiditis may be antibody negative."

without testing for the autoantibodies, it would be difficult to say hashimoto's for sure.

source: http://www.emedicine.com/med/topic949.htm

Up Vote Up Vote ×
Specializes in student; help!.

Yeah, we were looking at hyperparathyroidism but there aren't any Ca+ levels so we couldn't go with that. I know that she probably gives us exactly the labs and clues we need, but it's so tempting to look at other stuff (see: TBI in the last case).

Thanks for the links! I'll go check them out.

Up Vote Up Vote ×

As for the reference range for OGTT, there's a book on Google Books that has them for fasting, 30 min, 1 hr, 2 hr, 3 hr and 4 hr:

http://books.google.com/books?id=LOuL8W1UJKgC&pg=PA32&lpg=PA32&dq=ogtt+range+30+minute+lab+values&source=web&ots=gHG2jQk4H3&sig=gAGg0WoyVGFdFNxXr_i1t77nXU8&hl=en&sa=X&oi=book_result&resnum=4&ct=result#PPA33,M1

If that link doesn't work correctly, look for "Ocular Therapeutics" on Google books, and go to pages 32 and 33.

Fun!

Up Vote Up Vote ×
Specializes in student; help!.

Have I mentioned how awesome you guys are? AWESOME!

Up Vote Up Vote ×

Hey, cmonkey, I was just thinking of you. Do you read the CME cases on Medscape? They are great! Since you love patho and diagnostic puzzles, if you haven't checked them out, you might want to. You'll have to register first as a Medscape user, though. I was just reading the new CME on fibromyalgia...

http://cme.medscape.com

Up Vote Up Vote ×
Specializes in student; help!.

OMG, ya'll, this case is KILLING us. The ref ranges for some of the labs are so.far.apart that we don't know which to use. I'm going with ones I can duplicate from other sources, but still. If her calcitonin is normal, I go with one dx. If it's not, I go with another. And the difference is between

Plus? No H&P to speak of. I'm losing it. I'm sticking with hypothyroidism, but etiology unclear from data. It could be secondary to any number of other diseases but I just can't say. My dad wants me to point out that w/o evidence to contrary, getting the panel probably wasted a ton of her money. lol

Up Vote Up Vote ×
Specializes in student; help!.

Alright, I turned it in, called it hypothyroidism, but said it might could be Hashimoto if I had more labs. Then again, it could be a pituitary tumor, too. Not enough H&P or labs to tell.

Our group was all over the map on this one. Ought to be interesting when the grades come in!

Up Vote Up Vote ×
Alright, I turned it in, called it hypothyroidism, but said it might could be Hashimoto if I had more labs. Then again, it could be a pituitary tumor, too. Not enough H&P or labs to tell.

Our group was all over the map on this one. Ought to be interesting when the grades come in!

hmmm, well Hashi's is hypo....just a variety of.....i would be wondering something infectious....but no fever mentioned.....dont think acromegally would have such a sudden onset....what book do you use for class?

also, lab results have to be judged on the norms listed for that lab....different labs may use different tests and have different norms...so you would have to take "elevated calcitonin" at face value....

Up Vote Up Vote ×
Specializes in student; help!.

Right, but we don't get the ref ranges, we have to FIND normals. Which kind of sooks because I found one for PTH-C that was like 230-630, and two others that were 8-24 pg/mL. Um. That's a hell of a range, man.

I know Hashimoto is a type, but given the lack of h&p and antibody labs, I couldn't go for it. If you add information she doesn't give, she deducts points, so it didn't seem feasible to dx it on that basis alone.

No assigned textbooks, just whatever we can find. It's insane. But I kind of like it. I suppose that means I should work ER... :chuckle

Up Vote Up Vote ×
+ Join the Discussion