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Presentation at the 2014 Philippine Society of Endocrinology & Metabolism annual convention
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“Simple can be harder than complex:You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains.”
- Steve Jobs
Friday, March 21, 14
Iris Thiele Isip Tan MD, MScAssoc. Prof. 4, UP College of Medicine
Chief, Medical Informatics Unit
GPs asPituitaryStalkers
Pituitary Pathologies
Simplified
David and Goliath by Robert Temple Ayres
Friday, March 21, 14
to be aPituitaryStalker
How
optical_illusion_tshirt by Kevinhttps://flic.kr/p/a573df
Remember by clsawyerhttp://www.sxc.hu/photo/659706
Ask Remember Refer
Friday, March 21, 14
to be aPituitaryStalker
How
“The world is full of obvious things which nobody by any
chance ever observes.”- Sherlock Holmes
optical_illusion_tshirt by Kevinhttps://flic.kr/p/a573df
Have a questioning mind!
Ask
Friday, March 21, 14
David and Goliath
Who was
the real
underdog?
David and Goliath by Robert Temple Ayres
Friday, March 21, 14
DidGoliathacromegaly
have?
Friday, March 21, 14
David and GoliathPainting by Giovan Francesco Nagli
Height “6 cubits and a span” (2.5-3 meters)Slow-moving and ponderousGoliath saw “sticks”Stone sunk into foreheadGoliath fell forward
DidGoliathacromegaly
have
Friday, March 21, 14
38/F previously healthy
3-month history of
blurring of vision
headache by beermughttp://www.sxc.hu/photo/1413980
Friday, March 21, 14
Optometrist or ophthalmologist?
Prescribed eye glasses
Progressed to dimness of
vision
frame on eyechart by Brybshttp://www.sxc.hu/photo/1152188
Friday, March 21, 14
Diffuse throbbing headaches
followed by progressive blurring of visionFamily physician?
Internist?Neurologist?
headache by beermughttp://www.sxc.hu/photo/1413980
Friday, March 21, 14
Menses stopped 6 mos ago
followed by the
headaches
Gynecologist?
No galactorrhea
Endocrinologist?
headache by beermughttp://www.sxc.hu/photo/1413980
Friday, March 21, 14
Who makes the initial diagnosis of a pituitary lesion?
Diagnostic Source
Total percentage (n=404)Total percentage (n=404)Total percentage (n=404)Diagnostic Source Prolactinoma Non-functioning Acromegaly
Internist/Family Med 16 23 39Endocrinologist 34 14 25
Gynecologist 34 10 <1
Ophthalmologist/ Optometrist
6 25 6
Relatives/ self 2 1 6
Neurologist 0 3 5
Dentist 0 0 5
Other 8 24 14
Drange et al JCEM 85:168–174, 2000
Friday, March 21, 14
Pituitary adenomas come to clinical attention
mass effects
hormone excess
hormone insufficiency
Friday, March 21, 14
to be aPituitaryStalker
How
optical_illusion_tshirt by Kevinhttps://flic.kr/p/a573df
Remember by clsawyerhttp://www.sxc.hu/photo/659706
Ask Remember
Illness script
Friday, March 21, 14
Key Elements of the Clinical Diagnostic Reasoning Process Bowen J. NEJM
2006;355:2217-2225
Patient’s story
Data acquisition
Accurate “problem representation”
Generation of hypothesis
Search for and selection of illness script
Diagnosis
Knowledge
Context
Experience
Friday, March 21, 14
Expert clinicians store and recall knowledge as diseases, conditions, or syndromes - “illness scripts” - that are connected to problem representations.These representations trigger clinical memory, permitting the related knowledge to become accessible for reasoning.
A room lamp without lampshade by Mattoxhttp://www.sxc.hu/photo/1120345
Bowen J. NEJM 2006;355:2217-2225
Friday, March 21, 14
Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing conditions
Pathophysiological insult
Clinical consequences
Rare 17% of populationEqual sex incidenceIncidence increases with age
Tumor growthCompression of optic nerveExtension to cavernous or sphenoid sinusCompression of normal pituitary
Non-functioningpituitary adenoma
Friday, March 21, 14
By OpenStax College [CC-BY-3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons
and The Pituitary Optic Chiasm
Friday, March 21, 14
Image from http://www.medicinemcq.com/index.php/journals/sub_details/138/39/FMGE-MARCH-2012-ENT-AND-OPHTHALMOLOGY
and The Pituitary Cavernous Sinus
Friday, March 21, 14
Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing conditions
Pathophysiological insult
Clinical consequences
Rare 17% of populationEqual sex incidenceIncidence increases with age
Tumor growthCompression of optic nerveExtension to cavernous or sphenoid sinusCompression of normal pituitary
Nonspecific headacheVisual disturbances (bitemporal hemianopsia)Ophthalmoplegia, diplopia and/or ptosisCSF rhinorrheaAnterior pituitary failure (hypopituitarism)
Non-functioningpituitary adenoma
Friday, March 21, 14
Image from http://www.medicinemcq.com/index.php/journals/sub_details/138/39/FMGE-MARCH-2012-ENT-AND-OPHTHALMOLOGY
Bitemporal hemianopsia
Friday, March 21, 14
Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing conditions
Pathophysiological insult
Clinical consequences
Most common pituitary tumorF:M ratio 10:1
Neoplastic transformation of anterior pituitary lactrotrophs resulting in excess synthesis and secretion of prolactin
Prolactinoma
Oligo- or amenorrheaGalactorrheaErectile dysfunction or decreased libidoHypopituitarism (compression from large tumor)
Friday, March 21, 14
Hypergonadotropic hypogonadismOvarian failure
Hyper-prolactinemia
galactorrhea
headache
amenorrhea
Pituitaryadenoma
visual disturbances
Discriminating feature
Defining feature
Discriminating feature
Discriminating feature
Defining feature
Hypo-gonadotropic
hypogonadism
Friday, March 21, 14
Patient presenting with secondary amenorrhea;negative pregnancy test
Check TSH and prolactin levels
Both normal
Normal TSHAbnormal prolactin
Progestogen challenge test
No withdrawal bleed
Estrogen/progestogen challenge test
Withdrawal bleed
Normogonadotropichypogonadism
No withdrawal bleed
Outflow obstruction
Withdrawal bleed
Check FSH and LH
FSH >20 IU/LLH >40 IU/L
Hypergonadotropic hypogonadism
FSH & LH <5 IU/L
Perform MRI to evaluate for pituitary tumor
Normal MRI: hypogonadotropic hypogonadism
Normal prolactinAbnormal TSH
Thyroid disease
Prolactin <100 ng/mL(100 mcg/L)
Consider other causes
Prolactin >100 ng/mL
Perform MRI to evaluate for prolactinoma
Negative MRI
Friday, March 21, 14
What happens when you can’t match an illness script?
59/F with dizziness, vomiting and weakness ...
Rounadabout by ColinBroughttp://www.sxc.hu/photo/1265027
Friday, March 21, 14
Third time admitted for vomiting, dizziness and general weakness
Previous admissions also with hypoglycemia and pneumonia or UTI
Normal endoscopy end to end ...
What to do?!
Photo by Ashley Webbhttps://flic.kr/p/5u36oV
Friday, March 21, 14
Adrenal insufficiency?!
31 years ago Postpartum bleeding needing BT Delivered twins at homeRetained placenta
Screaming by ralaenin http://www.sxc.hu/photo/579286
Friday, March 21, 14
Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing conditions
Pathophysiological insult
Clinical consequences
5.1 per 100,000 womenSevere postpartum vaginal bleedingSevere hypotension or shock requiring fluid replacement or blood transfusion
Sheehan’s syndrome
Friday, March 21, 14
Friday, March 21, 14
Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing conditions
Pathophysiological insult
Clinical consequences
5.1 per 100,000 women (Iceland)Severe postpartum vaginal bleedingSevere hypotension or shock requiring fluid replacement or blood transfusion
Pituitary enlargementLactotroph hyperplasiaPituitary gland susceptible to ischemiaPostpartum pituitary necrosis
Failure of postpartum lactationFailure to resume regular mensesVarying degrees of hypopituitarismEmpty sella on CT scan or MRI
Sheehan’s syndrome
Friday, March 21, 14
Sheehan’s SyndromePresentation
At ER following a stressful event
Coma of hypothyroidismAdrenal insufficiencyHypoglycemiaHyponatremia
http://www.sxc.hu/photo/65898Ozkan& Kolac, Neuroendocrinol Lett 2005;26(3):257-60
Friday, March 21, 14
GH deficiency
Reduced energy and vitalityReduced muscle mass and strengthDecreased sweating and impaired thermogenesisIncreased central adiposityIncreased CV riskDecreased BMD
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
ACTH deficiency
Fatigue, weakness, anorexia, weight lossNausea, vomiting, abdominal painHypoglycemiaCirculatory collapse if acute onsetLoss of axillary and pubic hair in women
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
Gonadotrophin deficiencyMen: erectile dysfunction, soft testes, reduced muscle mass and energyWomen: oligo/amenorrhea, dyspareunia, breast atrophyBoth: loss of libido, flushes, infertility, regression of sexual characteristics, reduced BMD
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
TSH deficiencyFatigue, apathy, psychomotor retardationCold intolerance, dry skinConstipationWeight gain
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
45/Mreferred to surgeon for colon CA
Referred by surgeon
to me for coarse facial features
http://www.cinemainsomnia.com/lobo-loves-rondo-does-rondo-love-lobo/
Friday, March 21, 14
Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing conditions
Pathophysiological insult
Clinical consequences
40-70 cases per million populationMean age of onset 30 yOnset to diagnosis 5-15 yMean age at diagnosis: 40 y in men and 45 y in women
GH excessGH-secreting pituitary adenomas
Inc incidence of colonic polyps & colon adenoCA, diabetes, hypertension and CVDSoft tissue swelling & enlargement of extremitiesIncrease in ring and/or shoe sizeHyperhidrosisCoarsening of facial featuresPrognathism, macroglossia
Acromegaly
Friday, March 21, 14
Rondo HattonAmerican Actor
Acromegaly attributed to exposure to German mustard gas attack in World War I
http://i1139.photobucket.com/albums/n545/travislouie37/Rondoisgoodwiththeladies.jpg
Friday, March 21, 14
Sheehan’s syndrome
Non-functioning adenoma
hypopituitarism
Functioning Pituitaryadenoma
Discriminating feature
Defining feature
Discriminating feature
Discriminating feature
mass effects
ACTH
TSH
Excess secretion
PRL
GH
Hormone deficiency
Postpartum hemorrhage
Defining feature
Friday, March 21, 14
At rounds more than a decade ago with MALA ...How much does a
human pituitary gland weigh?
Seagull in front of sea by cobrasoft http://www.sxc.hu/photo/1437851
Friday, March 21, 14
“But what physician has not had patients who don’t make any sense at all? To tell the truth, they’re our stock-in-trade. We talk and write about the ones we can make sense of.”
- Walker Percy
Dr. House MD Caricature Hugh Laurie by Nelson Santoshttps://flic.kr/p/46tXvx
Friday, March 21, 14
to be aPituitaryStalker
How
optical_illusion_tshirt by Kevinhttps://flic.kr/p/a573df
Remember by clsawyerhttp://www.sxc.hu/photo/659706
Ask Remember Refer
Friday, March 21, 14
Thank You@endocrine_witch
Friday, March 21, 14