Endocrine May 24 Resident

INTERNAL MEDICINE BOARD REVIEWENDOCRINE SECTION

KING FAHAD SPECIALIST HOSPITAL-DAMMAMMAY-24-2012

Dr. Mohammad DaoudConsultant Endocrinologist

Internal Medicine DepartmentKFMMC

All reflects the standards of care for diabetic patients

Except:A- BP < 130/80 mmHg

B- LDL- Cholesterol of < 100 mg /dl ( < 2.6 mmol/L )

( < 70 mg /dl {1.8 mmol/L} ; very high risk )

C- Post -prandial capillary PG < 180 mg /dl ( < 10.0 mmol/L)

D- HbA1C < 8.0%

E- Pre-prandial capillary PG 70-130 mg/dl (3.9 - 7.2 mmol/L)

Treatment goals for DM patients

A- BP < 130/80 mmHg

B- LDL- Cholesterol of < 100 mg /dl ( < 2.6 mmol/L )

( < 70 mg /dl {1.8 mmol/L} ;very high risk )

C- Post -prandial capillary PG < 180 mg /dl ( < 10.0 mmol/L)

D- HbA1C < 7.0% √

E- Pre-prandial capillary PG 70-130 mg/dl (3.9 - 7.2 mmol/L)

Diabetes Mellitus Targets For Control (ADA-2012)

Parameter Goal ActionSuggested

AC Glucose Post-P Glucose

70-130 < 180

<70 or >140 >180

HS glucose 100-140 <100 or >160

HbA1c % <7 (6.5) >8

BP (mmHg.) 130/80 >130/80

LDL-Chol TG

<100 <150

>100

HDL-Chol >40 males >50 females

<40 <50

A young lady with Polyuria

A 40 yr old female patient presents to your clinic with symptoms of weakness and

excessive urination

PMH : CAD , Dyslipidemia & HTN on Rx

BP 144/88 BMI = 32 kg /m2

All can be an initial tests to evaluate this patient complaint

Except:

A- Plasma Glucose

B- Serum calcium

C- 24 hr urine volume

D- Water deprivation test

E-Serum and urine osmolarity

All will establish the DX of DM in this patient Except:

A- Fasting Plasma Glucose of ≥ 126 mg /dl (7.0 mmol/L)B- 2-hrs Glucose ≥ 200 mg/dl (11.1 mmol/L) during OGTTC- Random Glucose of ≥ 200 mg/dl (11.1 mmol/L) with symptomsD- HbA1C ≥ 6.5%

E- Fasting Plasma Glucose of = 120 mg /dl (6.6 mmol/L)

Need to know

D.Dx of Polyuria

Diagnostic Criteria of DMVs

Pre-diabetes

D.Dx of Polyuria(Osmotic or Water

diuresis)

Diabetes MellitusDiabetes InsipidusPrimary polydipsia

Hypercalcemia Others

FPG of 120 = IFG (Pre DM status )

Pre-diabetesIFG

FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG

ORIGT

2-h plasma glucose in the 75-g OGTT

140–199 mg/dL (7.8–11.0 mmol/L): IGTOR

A1C 5.7–6.4%

A middle aged male with Polyuria and Nocturia

A 45 year old male patient Presents with history of excessive urination for about 3 months

He describes drinking about 12 bottles of water ( each 700 ml ) over 24 hrs

He has to wake up 5-6 times /night to empty his bladder


No previous medical illness No medications on board / or OTC

No history of head trauma or falling down

No history of any prior surgeries

No psychiatric history


Exam: non-contributing

Labs: Normal : plasma glucose , serum

calciumNa 146 , Cr 80

24 hr urine collection : 6.5 liters

Urine Osmo. = 140 mOsmo / L (300-1000)

Male with Polyuria and NocturiaAll are proper indications for

termination of water deprivation test Except:

A-Patient becomes hemodynamically unstable

B-Weight loss of > 3-5 %

C-Diluted 2 consecutive urine samples despite Plasma osmolality ≥295-300 mOsmo /L

D-Plasma Na ≥ 145

E-Urine output of >500 ml/hr

Further workup

After 8 hrs of Water deprivation

Urine Osmo 140 , 160 Plasma Osmo. 299

Plasma Na 149

dDAVP 10 mcg introduced

Within 2 hr ;urine Osmo= 625 mOsmo/LUrine output : 350 ml …to 55 ml/hr

Least likely underlying etiology of polyuria in this patient is

A- Sarcoidosis

B- Hypothalamic lesion mass effect

C- Histocytosis X (Langerhans / eosinophilic granuloma)

D- Nephrogenic DI

E-Idiopathic ( ? Autoimmune) Central DI

To establish Dx of DI in patient with Polyuria and Nocturia

High Urine output > 3-4 L / 24 hrs(>50 ml/kg)

Dilute urine < 300-350 mOsmo/L

Failure to concentrate the urine despite adequate stimulus ( dehydration)

Pattern of response to exogenous ADH

Diagnosis of Central and nephrogenic diabetes insipidus

in a patient with polyuria

Type 2 DM Insulin Use Indications

A- Symptomatic hyperglycemia on presentation

B- Secondary failure of oral agents

C- Contraindication for oral agents D- Pregnancy

E- Acute de-compensation or stress (ex: peri- operative)

ALL ARE T

RUE

Old Lady with Polyuria

An 85 year old female patient was recently diagnosed with DM

She had Polyuria, nocturia, weight loss with a RBG of 455 mg/dl and

HbA1c 11.3 %

No family history of DM

Exam : Stable vital signs ; other wise unremarkable

Old Lady with Polyuria Recently Diagnosed with DM

She was started on Insulin twice daily

with good response ;FPG < 150mg/dl and HbA1c down to

7.4%

Still, she was complaining from poor appetite with no weight gain

F/Up lab results:

Normal TFT ,CBC : Hb 11 gm/dl Na 138 , K 4.0 , S.Cr 80


The best next step in evaluating this patient:

A- 24 –hr urine collection for Cr and ProteinB- Plasma AM Cortisol level C- CT of upper abdomen D- Serum lipase E-Gastric emptying study


Always think about possible

secondary causes of DM

Like Ca . Pancreas or Mets to Pancreas

Look for clues : ex: Cushingoid or Acromegalic

features

Old male with A. Fibrillation

A 70 yr old male patient with long standing DM type 2 and Hypertension Presented to ER with palpitation and

dizziness

Vital signs: BP 100/50 HR 140 (irregular , irregular )

ECG: A. Fibrillation with ;ventricular rate of 155 /min

Old male with A. Fibrillation

A 70 yr old male patient with A. Fibrillation

His baseline labs: S. Cr 90 (53-115 mmol/L)

,K 4.0 mmol/LGlucose 8.5 mmol/L

TSH 1.9 (0.4- 4.5 ) Free T4 16 (10-19 nmol/L)

FT3 6 (4.7-8.2 pmol/L)

What about this patient?A 70 yr old male with Atrial Fibrillation

He was started on Amiodarone

Was 1.9 16 6

2 weeks later TFT was repeated and

showed

TSH 9.5 FT4 11 FT3 2.4

A 70 yr old male with Atrial Fibrillation on Amiodarone with

deranged TFTWhat is your best next action ?

A- Start L-Thyroxin 50 mcg/d and repeat TFT in 6-8 weeks B- Do thyroid isotope scan C- No intervention ;Repeat TFT in 2-3 months D- Measure the thyroid Anti-TPO antibodies E- Thyroid Ultrasound

Amiodarone & TFT

Amiodarone is a lipophilic drug Rich in iodine ; 30% of tablet weight

A 200 mg tablets ; 65- gm of iodine Daily requirement 0.15-0.3 mg

One tablet provides up to 40- 100 days

of iodine needs !

Amiodarone & TFT

It inhibits T 4 → T3 (Pit / Peripheral)

Temporary high TSHLower T4 and T3

Reset balance in 3 months

Half-life of about 100 days Toxicity can occur well after drug

withdrawal

All are true statement about pharmacologic Rx of DM Except

A- Metformin is the cornerstone Rx unless C.I

B- Secondary failure is least with Metformin

C- Glitazones are C.I with CHF stage III-IV D- Sulfonylurea can cause hypoglycemia and weight gain

E- Metformin is C.I with renal impairment (Cr > 1.5 mg/dl) ( Lactic Acidosis Risk)

Pharmacologic Rx of DM

Type 2 DM is a progressive disease of

Beta Cells reserve loss with time

To date ; no definite treatment that

fixes such issue!

Contra-indications for Metformin

Renal dysfunction ; males ≥ 1.5 mg/dl or ≥ 1.4 mg/dL in females

Congestive Heart Failure /on treatment or hypo perfusion /shock status

Liver disease Contrast exposure

Acute or chronic metabolic acidosis; DKA

Young male with Hypertension

A 32 year old male patient

Diagnosed to have HTN 3 months ago

Referred for evaluation of possible secondary causes of

hypertension

Young male with Hypertension

He describes history of headache and poor energyHe denies palpitation ,sweating or flushing No body weight changes reported

No use of alcohol or illicit drugs

Family history : No HTN or hemorrhagic stroke

Commonest etiology for secondary HTN is

A- Pheochromocytoma

B- Cushing’s syndrome

C- Mineralocorticoid excess

D- Reno-vascular etiology

E- Obstructive sleep apnea

Causes OF Secondary HTN-1

Reno vascular dis.

Pheochromocytoma

Aldosteronoma

Cushing’s syndrome

Sleep apnea syndrome

Coarctation of aorta

Oral contraceptives

Clues for Secondary HTN

Unexplained/Easily provoked hypokalemia

Severe or Resistant HTN Adrenal Incidentalomasuggestive clinical picture of a

secondary cause e.x : Cushingoid features or classical picture of Pheochromocytoma

Suggestive Family History

Young male with HypertensionExam:

BP 150/110 both arms HR 78 /min regular

No radio-femoral pulse delay

Thyroid : Normal Chest /CVS Exam : Unremarkable Skin: No bruises or striae No buffalo hump or increased supra- clavicular pads of fat

Back to the case

Young with Hypertension

Investigations

Normal CBC ,TFT

Na 144 K 3.6 (3.6-5.2 mmol/L)

Serum Creatinine 74 ( 60-115 µmol /L)

HCO3 34 (22-29 mmol/L)

Calcium 2.4 (2.2-2.6mmol/L


Investigations

Renal Ultrasound/ Doppler : Normal

Treated with ACE(-) and HCTZ1 WEEK LATER:

BP 148/96Serum K dropped to 3.0 (3.6-5.2

mmol/L)Serum Creatnine 80 ( 60-115 mmol/L)


ACE(-) and HCTZ

Above medications replaced with CCB

BP improved but not to target

Normalization o f K level

Young with HypertensionBest next in evaluation is:

A- 24 hr urine collection for fractionated metanephrines and catecholaminesB- Plasma free metanephrines C- Plasma Aldosterone and Plasma ReninD- CT scan adrenalsE- Overnight 1 mg Dexamethasone suppression testing

Young with HypertensionBest next in evaluation is:

Hypertension with hypokalemia or easily provoked hypokalemia

…

Alkalosis

R/O state of Mineralocorticoid excess

Conn’s is the commonest

Old lady with back pain

A 70- year old lady with history of DM-Type 2 and Rheumatoid arthritis for

many years

Consults you regarding her concerns about being osteoporotic since her mother had osteoporosis with hip

fracture


Current medications include Insulin

Prednisone 10 mg OD No HRT

ROS:

Menopause at age of 51 yrsLoss of height


Exam :

Weight 87 kg , Height 162 cm BMI 33 kg/m2

Mild kyphosis No bone tenderness

Labs: Calcium 2.25 mmol/L

Albumin 40 gm/L25-Vitamin D (pending)

Old lady with back painAll are risk factors for osteoporosis

Except A- Positive parental history of osteoporosis B- Rheumatoid arthritis

C-Obesity

D-Postmenopausal state

E- Long term use of glucocorticoids

Old lady with back painThe most important risk factors for

osteoporosis

A- Positive parental history of osteoporosis B- Rheumatoid arthritis

C-Obesity

D-Postmenopausal state

E- Long term use of glucocorticoids

Know the risk factors for osteoporosis

Age / Sex ( Females >>Males)+ve parental history

Previous fracturesRheumatoid arthritis

Underweight / Lean body (ht/ wt /BMI)

Postmenopausal state / Hypogonadism

Know the risk factors for osteoporosis

Glucocorticoids use ( ≥ 3 months /≥ 5 mg Prednisolone)

Current Smoking

Alcohol ;≥ units/daySecondary osteoporosis

( Hypo- gonadism or Premature menopause, Mal-absorption, CLD, IBD)

FRAX tool -12 factors

Age SexHeight WeightCurrent Smoking Alcohol ;≥ units/dayPrevious fractures Rheumatoid arthritisParental fracture

Glucocorticoids use ( ≥ 3 months /≥ 5 mg Prednisolone)

Secondary osteoprosisBMD

A Man with Osteoporosis A 55 year old male, referred for

management of osteoporosis Dx based on DXA scan ( T-score -3.0 both spine and

hips)

PMHx:HTN & DM diagnosed 2 yrs ago (On Rx )

ROS: Progressive weight gain over last 3 years

Smoker for 30 yrs Denies any sexual dysfunction

Rx: Metformin 1 gm. BID and Perindopril 5 mg OD

A Man with Osteoporosis

Exam: BP 144/92 HR 80/min

weight 96 kg Height 168 cm BMI 34 kg/m2

Moon face changes Fresh striae over abdomen and

extremities Proximal muscle wasting and

weakness Dark/ pigmented skin

http://localhost:4728/

A Man with Osteoporosis

Labs: Normal :CBC , S. Lytes ,Calcium

profile and TFT ,

24 hr urine collection for UFC : 4 times upper normal

1 mg Dexamethasone suppression test :

No suppression 8 mg Dexamethasone suppression

test : No suppression

A Man with Osteoporosis Your best next step in evaluation of

this patient is :

A- Pituitary MRI B- IPSSC- CRH stimulation testD- Plasma ACTH E- Adrenal CT scan

Plasma

ACTH : 110 (2-11

pmol /L)

A Man with Osteoporosis The least likely etiology /source of this

patient disease is :

A- Pituitary Adenoma B- Pancreatic neuroendocrine tumorsC- Adrenocortical carcinomaD-Bronchial carcinoid tumor E- Ectopic CRH secreting tumor

A Man with Osteoporosis Discussion

-The patient has florid Cushing’s syndrome

-Failure to suppress with high dexamethasone …against

pituitary source ( Cushing’s disease)

First step in evaluation of confirmed state of hyper-

cortisolemia ….Plasma ACTH

A Man with Osteoporosis Discussion

-Ectopic source is very likely with history of smoking , skin pigmentation , failure of suppression to high Dexa. Dose

Adrenocortical Ca. = Low ACTH

Common Causes of Cushing Syndrome

Cause % of Patientsa

Endogenous Cushing syndrome

ACTH-dependent 75-80

ACTH-secreting pituitary adenomas 60-65

Ectopic ACTH secretion by tumors 10-15

CRH-secreting tumors <0.5

ACTH-independent 20-25

Adrenal adenoma 10-15

Adrenal carcinoma 5-10

Exogenous Cushing syndromeAdministration of corticosteroids (prednisone, dexamethasone, hydrocortisone)b

—

Administration of drugs with corticosteroid activity (progestational agents, such as megestrol acetate)

—

Pregnant with Hypothyroidism

A 29 yr old female patient with history of

primary hypothyroidism

On L-Thyroxin 100 mcg daily

TFT 3 -months ago : TSH 2.0 FT4 13.5

Pregnant with Hypothyroidism

Currently she pregnant ( GA 10 weeks)

ROS: Excellent compliance to treatment

No complaints

TFT done 2 day ago : TSH 7.3 FT4 11

She is concerned about her baby with this current TFT?

Pregnant with Primary Hypothyroidism on Rx

The best statement/action at this stage is ?A- She can be assured/continue same

treatment B- Advise her to increase her intake of sea food

C- The fetus produces adequate T4 at this stage of pregnancy

D- Increase her L-T4 dose to 125- 150 mcg/day and repeat TFT in 6 wks

E- No risk for the fetus with such TFT

Same alpha-subunit

hCG and TSH Considerable Similarity

hCG peak effect at 10-12 weeks hCG has weak thyroid-stimulating activity

PREGNANCY- THYROID ADAPTATION

hCG and TSH

NORMAL PREGNANCY Trimester-specific reference ranges

The TSH (mU/L) reference ranges can be used:

* First trimester 0.1 to 2.5* Second trimester 0.2 to 3.0 * Third trimester 0.3 to 3.0

Guidelines of the American Thyroid Association (ATA) for the Diagnosis and Management of Thyroid Disease During

Pregnancy and Postpartum

Higher hCG means lower TSH

GA 10 weeks:

TSH 7.3

FT4 11

Know the impact of pregnancy on TFT and L-T4 requirement

Trimester-specific reference range

The fetus is almost totally dependent on the mother for thyroid hormone

Thyroid and PregnancyNeed to Know

Psychiatric patient with abnormal TFT

A 28 year old female patient with history of schizophrenia presenting with

acute exacerbation of her psychosis

She lost about 10 kg over 4 months Poor sleeping w palpitation , heat intolerance with irregular menses

Family history : ++ members with autoimmune thyroid disease

Exam:

HR 124 /minute regular , BP 140/90

Restless , anxious with sweaty palms

+ve tremors , lid lag and “stare” No exophthalmos+3 brisk reflexes

Thyroid : Not palpable


Investigations :

Free T4 39 nmol/L ( 10-19)TSH <0.002

Thyroglobulins: 3 ng /ml ( < 40 )

Thyroid scan : 0.2 % ( 0.4-4%)



Psychiatric patient with abnormal TFT The most likely diagnosis is

A- Struma ovarii

B- Amphetamine abuse

C- Factitious hyperthyroidism

D- Hyper- thyroxinemia due to acute psychosis

E- Hyper- thyroxinemia due to estrogen ingestion

A patient with psychiatric history

Family history of thyroid disease ( ?access to L-T4 Rx)

Impalpable thyroid and

low Tg & low uptake scan =

Factitious hyperthyroidism


Discussion

Male patient with fatigue

A 48 year old male patient presents to you with a complaint of fatigue and cold intolerance

He is known to have DM type 2 for 10 years and CAD

He underwent CABG 3 months ago ; was complicated by excessive blood loss and prolonged hypotension for few hours after which he pulled through ,luckily !!


ROS:Cold intolerance Decreased libido with erectile dysfunctionNo visual complaint

Exam :Stable vital signs Mild pallor No goiter Otherwise : unremarkable


The least likely lab result compatible with his clinical setting

A- Testosterone 8 (13-30 nmol/L) and LH < 0.1 (1.1-9.0 mIU/ml) B- F.T4 6 (10—21 pmol/L ) and TSH 70 (0.4-4.5 mIU/L0) C- Prolactin 2 (4-19 ng/ml )

D- Evening serum cortisol 60 ( 88-440 nmol/L )

E-GH undetected


This patient setting equals females Sheehan's syndrome

Think Central

Hypo-Pituitary state :Variable degrees

Can’t rely on trophic hormones ;ex:TSH

High TSH = Primary hypothyroidism

A woman with weakness

A 45 year old female patient presents to OPD with

6 months progressive history of weakness and generalized body

aches


A45 year old female

She denies any significant medical history

Smoker for 25 years

Documented weight loss of 12 kg over last 6 months

She is not dieting

She has no menses for last 8- monthsNo medications or supplements on board


Exam:Weight 50 kg Height 170

cm BP 110/55 , HR 116/min , Afebrile

Cachectic patientNo lymphadenopathy Breast : unremarkable

Otherwise ;not contributing


Investigations

FPG 5.0 mmol/LNa 140K 4.0

S. Creatinine 145 (53-115mmol/L)


Investigations

Calcium 3.0 (2.2-2.6 mmol/L)

Albumin 30 (35-50 g/L)Mg 0.9 (0.7- 1.3 mmol/L)

Phosphorous 0.8 (0.8-1.6 mmol/L) Alkaline Phosphatase 220 (50-136

U/L)


Investigations

Serum Prolactin 450 (2-20 ng/ml)

CXR : Rt. sided lung mass

A woman with weakness (1)What is your next step in workup of

Hypercalcemia in this patient?

A- Mammogram

B- 25-Vitamin D level

C- Parathyroid hormone level

D- 24 hr urine collection for calcium and Cr.

E- Lung biopsy

A woman with Hypercalcemia and lung mass

Investigations Normal Mammogram

25-Vitamin D level : 75 (50-150 nmol/L)

Parathyroid hormone level: 120 (10-65 ng/L)

24 hr urine collection: Calcium 600 mg (15 mmol)

Bronchoscopy : Squamous cell carcinoma

A woman with weakness (2)Her most likely etiology of

Hypercalcemia:A- Breast Cancer

B- Vitamin D Intoxication

C- Primary hyperparathyroidism

D- Familial Hypocalciuric Hypercalcemia (FHH)

E- Squamous cell carcinoma (Para neoplastic)

A woman with weakness (3)All are possible components of MEN-

1 except:A- Prolcatinoma

B-Tongue Neuromas

C- Primary hyperparathyroidism

D- Pancreatic tumors (Gastrinoma…)

E- Acromegaly

Evaluation of HypercalcemiaPTH mediated Vs. non-PTH mediated

Squamous cell carcinoma /PTHrP ?

Coexisting tumors

Vitamin D Intoxication…suppressed PTH

Familial Hypocalciuric Hypercalcemia (FHH): low urinary calcium

Intact PTH

pH PTH FHH

Diagnostic approach to Hypercalcemia

PTHrp and Vit. D metabolites

A lady with Goiter

A 45 yr old Saudi female patient –from Khobar- underwent a second

thyroid surgery for managing a large goiter

Goiter was extending retrosternaly with pressure symptoms with diffuse

lymph nodes enlargement

Histopathology proved to be papillary thyroid cancer (after an initial

subtotal thyroidectomy)

A lady with Goiter

Past Medical History:

-History of gastric bypass surgery 2 yrs ago for management of morbid obesity

-She has poor compliance for her prescribed supplements

-History of use of PPI for management of GERD

A lady with Goiter

Post Operatively :

12 hrs after surgery she was complaining from numbness of upper and lower extremities with muscle twitches

On exam: Body weight 72 kg

She had carpal spasm while BP was measured

A lady with Goiter

Post Operative Labs:

Serum Calcium 1.55 mmol/L (6.2 mg/dl)

Albumin 38 Phoshporous low -normal

Alkaline Phosphatase high -normal

A lady with GoiterAll are characteristic of a patient with higher risk of Post-thyroidectomy symptomatic hypocalcaemia EXCEPT A- Large goiter

B- History of Hypothyroidism

C-Reoperation

D-Pre-Op low calcium or vitamin D levels

E-Calcium malabsorption

Higher risk (Predictors) of Post-thyroidectomy symptomatic

hypocalcaemia

Large goiter Reoperation

LymphadenectomyGraves disease

Coexistent Primary Hyper PTH Pre-Op low calcium or vitamin D levels

Breast feedingCalcium malabsoption; PPI /Bypass

surgery/Celiac

All are appropriate steps in management of this patient hypocalcaemia EXCEPT

A- Measure PTH and Vitamin D levels

B- Two vials of Calcium Chloride 10% over 20 minutes and re-measure calcium after 8-12 hrs

C- Two vials of Ca- Gluconate 10% then IV infusion (5-6 vials in half liter D5W at rate of 70 ml/hr)

D- Concomitant oral Calcium and Vitamin supplement E- Measure Mg level and supplement as needed

Calcium Chloride 10% is highly concentrated (270 + mg/vial)

and should be avoided ….extravasations risk

Ca- Gluconate 10% = 93 mg/vial

Established formula for managing symptomatic hypocalcaemia = 5-6 vials in half liter D5W at rate of 70 ml/hr )

Management of Symptomatic Hypocalcaemia

Management of Symptomatic Hypocalcaemia

Pre-existing Hyper-PTH Vitamin D def. means more likely hood for post-op Hypocalcemia …

Hypo-Mg …should be fixed to at same time ;Impairs PTH secretion and contributes to PTH resistance

Concomitant oral Calcium and Vitamin supplement…but not adequate on its own …at least early on

Calcium Content

Type , Amount Elemental Calcium

1gm Ca Gluconate 93 mg

1gm Ca Chloride 273 mg

1250 mg Ca Carbonate

(40% Ca) 500 mg

1900 mg Ca Citrate (21% Ca) 400 mg

Young lady with weakness

A30 yr old Saudi female presents to your clinic with weakness and diffuse body aches

She has no past medical history

Regular menses

No medication on board

She was worried about osteoporosis since her mother has it


She is married for 13 yrs

Gravida 7 / Para 7 ; youngest is 2 yrs and oldest is 11 yrs

Breast fed all her children


Exam:

Stable vital signs

Diffuse tenderness over bones

No bone deformities


Labs : Hb 10.3 g/LChemistry:

Na 136 , K 4 , Cr 77

Calcium 2.1 (2.2-2.6 mmol/L)

Phosphorous 0.8 (0.8-1.3 mmol/L)

Alkaline phoshpatase 300 (50-136 u/L )

Young lady with weaknessMost likely diagnosis is:

A- Sickle cell disease with VOC

B- Osteoporosis

C- Osteomalacia with vitamin D deficiency

D- Polymyalgia Rhematica

E- Primary Hypo- parathyroidism

Young lady with weaknessMost likely diagnosis is:

Osteomalacia with vitamin D deficiency

Vitamin D deficiency is so common in KSAUp to 80% prevalence in females (many studies)Up to 40 % prevalence in males

Low calcium , low phosphorous and high alkaline phosphatase ….with secondary hyper PTH ….makes the story

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Endocrine May 24 Resident