Endocrine or Not Endocrine

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Endocrine or Not Endocrine Powered By Docstoc
					                                        5/11/2012




           Mako E. Sather, CPNP
       Pediatric Endocrine Associates
          Greenwood Village, CO




   There is no conflict of
    interest.




               Content

In a game show format,
show the importance of
complete assessments of
patients with various
conditions to determine if
they are endocrine or not
endocrine in origin.




                                               1
                                                                     5/11/2012




 Short             Breast
stature Thyroid development




                   Jordyn              Lily             Brynn
                (11yr 3mo F)       (7yr 5mo F)       (9yr 6mo F)
   History/
  review of
                      ?                 ?                 ?
   systems
Past medical
  history
                      ?                 ?                 ?
   Exam
                      ?                 ?                 ?
  Labs and
    X-ray
                      ?                 ?                 ?
                  Endocrine         Endocrine         Endocrine
                       or                or                or
                 Not endocrine     Not endocrine     Not endocrine




                 Jordyn              Lily             Brynn
              (11yr 3mo F)       (7yr 5mo F)       (9yr 6mo F)
 History/     •Always          •Growth rate      •Deceleration
review of     tracking         slowed at         in growth
 systems      <3%ile           age 3.            velocity (age
              •ROS benign      •has not lost     5: 25%, now:
                               baby teeth        10%)
                               •Chronic          •ROS benign
                               constipation
                Endocrine         Endocrine         Endocrine
                     or                or                or
               Not endocrine     Not endocrine     Not endocrine




                                                                            2
                                                             5/11/2012




                Jordyn           Lily           Brynn
             (11yr 3mo F)    (7yr 5mo F)     (9yr 6mo F)
Past medical •Term,          •Term,          •Term,
  history    6#9oz,          8#12oz          7#11oz, 21in
             19.7in          •Neuro-         •Neuro-
             •Neuro-         development     development
             development     normal          normal
             normal          •No medical     •Seasonal
             •Mild asthma    conditions      allergies
              Endocrine       Endocrine       Endocrine
                   or              or              or
             Not endocrine   Not endocrine   Not endocrine




                Jordyn           Lily           Brynn
             (11yr 3mo F)    (7yr 5mo F)     (9yr 6mo F)
   Exam      •Ht:0.6%        •Ht: 0.09%      •Ht:26.4%
             •Wt: 0.4%       •Wt: 5.9%       •Wt: 28.1%
             •BMI: 10%       •Mild           •BMI: 25-50%
             •Tanner II      myxedema        •Tanner I
             thelarche       •Thyroid not    thelarche and
             Tanner I        palpable        pubarche
             adrenarche      •Tanner I
                             pubarche
                             and
                             adrenarche
              Endocrine       Endocrine       Endocrine
                   or              or              or
             Not endocrine   Not endocrine   Not endocrine




                Jordyn           Lily           Brynn
             (11yr 3mo F)    (7yr 5mo F)     (9yr 6mo F)
 Labs and    •Bone age 8yr   •Bone age 5yr •Bone age 9yr
   X-ray     •CBC, ESR,      6mo           (3¼in below
             CMP, TFT        •TSH: 285     mid-parental)
             normal          •Free T4:     •CBC, CMP,
             •IGF-1          <0.30         ESR, TFT,
             :172(111-                     TTG normal.
             551)                          •IGF-1: 264
             •46XX                         (74-388)
             •TTG:>100U/                   •46XX
             ml
              Endocrine       Endocrine       Endocrine
                   or              or              or
             Not endocrine   Not endocrine   Not endocrine




                                                                    3
                                                                 5/11/2012




                   Jordyn           Lily            Brynn
                (11yr 3mo F)    (7yr 5mo F)      (9yr 6mo F)
  Labs and                                       GH stim:
    X-ray                                        glucagon:3.1
                                                 Arginine: 9.8
                 Endocrine       Endocrine        Endocrine
                      or              or               or
                Not endocrine   Not endocrine    Not endocrine




    Jordyn                 Lily                    Brynn
 (11yr 3mo F)          (7yr 5mo F)              (9yr 6mo F)

Endocrine           Endocrine Endocrine
 Or not              Or not    Or not
endocrine           endocrine endocrine




                                                                        4
                                             5/11/2012




    Jordyn           Lily         Brynn
 (11yr 3mo F)    (7yr 5mo F)   (9yr 6mo F)

    Not         Endocrine Endocrine
Endocrine        Or not    Or not
  (celiac       endocrine endocrine
 disease)




    Jordyn           Lily         Brynn
 (11yr 3mo F)    (7yr 5mo F)   (9yr 6mo F)

    Not    Endocrine Endocrine
Endocrine   (hypo-     Or not
  (celiac thyroidism) endocrine
 disease)




   Jordyn           Lily          Brynn
(11yr 3mo F))   (7yr 5mo F)    (9yr 6mo F)

    Not    Endocrine Endocrine
Endocrine   (hypo-        (GH
  (Celiac thyroidism) deficiency)
 disease)




                                                    5
                                                             5/11/2012




                        Celeste              Luis
                      (7yr 8mo F)       (9yr 10mo M)
History/ review
  of systems
                            ?                  ?
 Past medical
    history
                            ?                  ?
    Exam
                            ?                  ?
   Labs and
     X-ray
                            ?                  ?
                       Endocrine          Endocrine
                            or                 or
                      Not endocrine      Not endocrine




                       Celeste                 Luis
                     (7yr 8mo F)          (9yr 10mo M)
  Exam            •Ht: 72.7%           •Ht: 75%
                  •Wt: 59.7%           •Wt: 97%
                  •BMI: 25-50%         •BMI: 97%
                  •No acne,            •No acne, no facial
                  hirsutism, or        hair
                  axillary hair        •Tanner IV
                  •Tanner II-III       pubarche, I
                  thelarche, I         adrenarche 2cc
                  adrenarche           testes
                      Endocrine             Endocrine
                           or                    or
                     Not endocrine         Not endocrine




                        Celeste              Luis
                      (7yr 8mo F)       (9yr 10mo M)
 Past medical      •Term, 7#11oz,      •38wk, 6#2oz,
    history        20in                22in
                   •no                 •no
                   hospitalizations,   hospitalizations,
                   surgeries or        surgeries, or
                   medical             medical
                   conditions          conditions
                       Endocrine          Endocrine
                            or                 or
                      Not endocrine      Not endocrine




                                                                    6
                                                        5/11/2012




                      Celeste               Luis
                    (7yr 8mo F)        (9yr 10mo M)
History/ review   PCP noticed         Mom noticed
  of systems      breast buds at      breast buds 3mo
                  WCC 3mo ago.        ago. They have
                  Mom states no       been slowly
                  significant         increasing in
                  changes since       size.
                  then. No
                  leukorrhea or
                  vaginal bleeding.
                     Endocrine           Endocrine
                          or                  or
                    Not endocrine       Not endocrine




                      Celeste               Luis
                    (7yr 8mo F)        (9yr 10mo M)
   Labs and       • BA: 8yr, 6mo      •Growth chart
     X-ray        later 10yr          tracking for
                  •Growth chart       height, weight
                  was tracking,       steadily
                  now increased       increasing
                  velocity of         •Labs: all
                  8.8cm/yr            normal, except
                  •Labs: normal       total estrogen
                  thyroid function    moderate
                     Endocrine           Endocrine
                          or                  or
                    Not endocrine       Not endocrine




                                                               7
                                                             5/11/2012




                        Celeste                Luis
                      (7yr 8mo F)         (9yr 10mo M)
History/ review   No estrogen,           Estrogen cream
of systems        lavender oil or        use by mom-
                  tea tree oil use.      they slept in the
                                         same bed until 2
                                         weeks ago.
Labs:             GnRH stim: LH
                  max
                  9.28mIU/mL
                       Endocrine            Endocrine
                            or                   or
                      Not endocrine        Not endocrine




          Celeste                          Luis
        (7yr 8mo F)                   (9yr 10mo M)

 Endocrine     Endocrine
      or            or
Not endocrine Not endocrine




          Celeste                          Luis
        (7yr 8mo F)                   (9yr 10mo M)

   Endocrine                  Endocrine
  (precocious                      or
    puberty)                 Not endocrine




                                                                    8
                                                                  5/11/2012




            Celeste                        Luis
          (7yr 8mo F)                 (9yr 10mo M)

      Endocrine                  Not endocrine
     (precocious                   (external
       puberty)                  estrogen use)




                 Victoria      Nicole        Mary
               (17yr 8mo F) (13yr 1mo F) (16yr 3mo F)
  History/
 review of
                     ?                ?                ?
  systems
Past medical
  history
                     ?                ?                ?
   Exam
                     ?                ?                ?
 Labs and
   X-ray
                     ?                ?                ?
                Endocrine         Endocrine       Endocrine
                     or                or              or
               Not endocrine     Not endocrine   Not endocrine




                 Victoria      Nicole        Mary
               (17yr 8mo F) (13yr 1mo F) (16yr 3mo F)
  History/     •referred by      •referred by    •referred by
 review of     GYN for           psychiatrist    PCP
  systems      goiter            for abnormal    •tired x3-4mo
               •In retrospect:   labs            •Irregular
               tired x6mo,       •ROS benign     menses, LMP:
               menorrhagia,                      4-5mo ago
               otherwise                         •weight gain
               ROS benign.                       •constipation
                                                 •Irritability/
                                                 mood swings
                Endocrine         Endocrine       Endocrine
                     or                or              or
               Not endocrine     Not endocrine   Not endocrine




                                                                         9
                                                                  5/11/2012




                  Victoria      Nicole        Mary
                (17yr 8mo F) (13yr 1mo F) (16yr 3mo F)
Past medical    •Birth hx        •Birth hx        •Birth hx
  history       benign           benign           benign
                •PE tubes at     •Anxiety         •No hosp.,
                age 10mo         disorder- on     surgeries or
                •Tonsillectom    meds x2yrs       medical
                y at age 10yr    (social skills   conditions
                                 improving)
                  Endocrine        Endocrine       Endocrine
                       or               or              or
                 Not endocrine    Not endocrine   Not endocrine




                 Victoria           Nicole            Mary
               (17yr 8mo F)      (13yr 1mo F)     (16yr 3mo F)
  Exam      •Ht: 75-90%          •Ht: 75%         •Ht: 50%
            •Wt: >>97%           •Wt: sl>97%      •Wt: 97%
            •HR:72,              •HR: 108         •HR: 100
            BP:110/78            •BP: 134/68      •BP: 116/72
            •Thyroid             (on atenolol     •Thyroid not
            palpable 9cm         for anxiety)     enlarged.
            each lobe, no        •Thyroid 6cm     •abdominal
            nodules.             to each lobe     mass
            •Mild                •Moderate
            acnathosis           exophthalmos
                Endocrine          Endocrine       Endocrine
                     or                 or              or
               Not endocrine      Not endocrine   Not endocrine




                  Victoria      Nicole        Mary
                (17yr 8mo F) (13yr 1mo F) (16yr 3mo F)
 Labs and       •TSH:            •TSH:            •TSH:
   X-ray        8.3uIU/ml        0.04uIU/ml       1.4uIU/ml
                (0.4-5.8)        •Free T4:        •Total T4:
                •Free            3.79ng/dL        14.0ug/dl
                T4:0.8ng/dL      •Total T3:       (4.5-12.0)
                (0.9-1.8)        430ng/dl         •Free T4:
                •TPO:            996-211)         1.6ng/dl
                >6500U/ml        •TSI: 203%       •TSI: neg
                •TSI: neg.       (<129)           •TPO: neg
                  Endocrine        Endocrine       Endocrine
                       or               or              or
                 Not endocrine    Not endocrine   Not endocrine




                                                                        10
                                              5/11/2012




   Victoria        Nicole          Mary
 (17yr 8mo F)   (13yr 1mo F)   (16yr 3mo F)


Endocrine Endocrine Endocrine
   or        or        or
   Not       Not       Not
endocrine endocrine endocrine




   Victoria        Nicole          Mary
 (17yr 8mo F)   (13yr 1mo F)   (16yr 3mo F)


 Endocrine Endocrine Endocrine
  (hypo-       or        or
thyroidism)    Not       Not
            endocrine endocrine




                                                    11
                                                            5/11/2012




   Victoria               Nicole                 Mary
 (17yr 8mo F)          (13yr 1mo F)          (16yr 3mo F)


 Endocrine Endocrine Endocrine
  (hypo-    (Graves     or
thyroidism) Disease)    Not
                     endocrine




   Victoria              Nicole                  Mary
 (17yr 8mo F)         (13yr 1mo F)           (16yr 3mo F)


 Endocrine Endocrine     Not
  (hypo-    (Graves   endocrine
thyroidism) Disease) (Pregnancy)




     Hope you had fun!


                Take home message
     Full assessment is necessary.
     It is not always what it looks like.
     Ask the right questions.


                                              Thank you.




                                                                  12

				
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