17.4 – Endocrine System Diseases, Disorders and Diagnostic Testing

Use the words below to fill in the consultation report:

• menstrual
• palpitations
• conjunctival
• antibodies
• side effects
• medications
• discontinue
• elevated

PATIENT NAME: Jane SMITH
AGE: 26
SEX: Female
DATE OF CONSULTATION: January 15, 2020
CONSULTING PHYSICIAN: Mary Johnstone, MD, Internal Medicine
REASON FOR CONSULTATION: Hyperthyroidism; Graves disease.
PATIENT NAME: Jane SMITH
AGE: 26
SEX: Female
DATE OF CONSULTATION: January 15, 2020
CONSULTING PHYSICIAN: Mary Johnstone, MD, Internal Medicine
REASON FOR CONSULTATION: Hyperthyroidism; Graves disease.
HISTORY: Around 2 months ago she started noticing ________[Blank 1] and peripheral tremor. She was feeling more anxious and edgy. She had a 10-pound weight loss despite eating well. She was having some heat intolerance and diarrhea, and her ________[Blank 2] cycles were irregular. She also noticed her eyes were different. She went to see her family doctor who did lab work and was found to have a TSH suppressed with a free T4 around 40 and free T3 around 10. She then had a 24-hour thyroid uptake and scan that was abnormal with a 24-hour of 70 and a diffuse pan with a homogeneous pattern percentage in keeping with Graves disease. Her TSI was _______[Blank 3] at around 30.

PHYSICAL EXAMINATION: On physical exam her blood pressure was 140/60, heart rate was 120 with regular rhythm. She had mild proptosis with no infection of the _________[Blank 4] area. Normal eye movement. No pretibial myxedema. She had a diffuse goiter of around 60 g with no murmur and no nodularity. No abnormal lymphadenopathies. There was a positional tremor. Her weight was 90 pounds.

SOCIAL HISTORY: Jane has no significant past medical history. She is finishing her fourth year in biological studies. She is also working on a part-time basis. She is not aware of a family history of thyroid disease. She is currently on no medications. She is a smoker, around 15 cigarettes a day. She rarely drinks alcohol. She denies marijuana use.

SUMMARY: Jane presents with Graves disease. She has hyperthyroidism positive __________[Blank 5] and an increased thyroid uptake and a thyroid scan in keeping with her condition.
We talked about different repair options. We discussed Tapazole versus radioactive iodine. We discussed the pros and cons of each treatment option. She preferred to start on Tapazole. We talked about the potential __________[Blank 6] of these medications including the risk of rash, increasing liver enzymes, and the rare risk of agranulocytosis. I explained to her that if she has a mild or high fever, she should have her CBC checked through the ER, and if there is evidence of a granulocytosis, she cannot resume Tapazole. Usually Tapazole is well tolerated.

PLAN: I have started her on Tapazole 30 mg, and she will repeat lab work in a month and see me at that point. I explained to her that usually 8-18 months of treatment are necessary. Response varies from patient to patient. Frequent levels are necessary to adjust the _________[Blank 7] according to response.

If she has side effects to Tapazole or there is no response, or she is experiencing regular flares, then she should ________[Blank 8] the use of the Tapazole. Other options such as radioactive viral can be considered. I would not favour radioactive iodine in her case as she is a smoker and that she has had a mild ophthalmopathy. Radioactive iodine can worsen ophthalmopathy, therefore it should be avoided in smokers.
We talked about the importance of discontinuing smoking as it can worsen the disease.

________________________________
Mary Johnstone, MD, Internal Medicine

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Use the words below to fill in the consultation report:

• diabetes
• metabolic
• palpitations
• neuropathy
• congestive
• rhythm
• pulses
• diuretics
• sugars
• vascular disease
• edema

PATIENT NAME: Margaret JONES
SEX: Female
AGE: 56
DATE OF CONSULTATION: January 15, 2020
CONSULTING PHYSICIAN: Mary Johnstone, MD, Internal Medicine

REASON FOR CONSULTATION: Type 2 diabetes.

HISTORY: I saw Margaret as a follow up today in regards to poorly controlled type 2 ________[Blank 1]. She is reluctant to make any changes in her current medications. She is very afraid of side effects of all her medications. She has not been testing her blood sugar but is planning to start doing it again.
Unfortunately, Mary did not do lab work prior to seeing me. I do not have an updated lab work for at least 2 years. It is very difficult to assess her __________[Blank 2] control without any information.
She continues to be sedentary, but she tells me she has no chest pain or shortness of breath when doing the chores around the house or going up or down the stairs. She denies of orthopnea, ankle swelling, _________[Blank 3], presyncope or syncope.

PAST MEDICAL HISTORY

1. Type 2 diabetes diagnosed 2009. Advanced microvascular complications including non-proliferative retinopathy. Nephropathy with significant microalbuminuria. No ___________[Blank 4]. Positive coronary artery disease and peripheral vascular disease. Poor control for several years.
2. Coronary artery disease. CABG 4 in 2019. LIMA to LAD SVG to OM and RCA. Grade 2 left ventricular function. Previous episodes of ____________[Blank 5] heart failure preserved ejection fraction with regular admissions due to volume overload.
3.  Hypertension.
4.  Hypercholesterolemia.
5.  Smoker.
6.  Alcohol, 5-8 beers a week.
7.  Obesity.
8.  Peripheral vascular disease, femoral popliteal bypass in 2017.

MEDICATIONS
Aspirin 81 g q.d..
Bisoprolol 5 mg q.d.
Ramipril 20 mg q.d.
Rosuvastatin 20 mg q.d.
Invokana 300 mg q.d.
Tresiba 20 units q.d.
Metformin 1 b.i.d.
Ozempic 1 mg q.wk.

PHYSICAL EXAMINATION: On physical exam her weight was 100 kg. Blood pressure 160/70, heart rate 88/min. Sa and S2 were heard in 4 areas with regular __________[Blank 6]. There is a 2/6 systolic murmur best heard in aortic area with no radiation. Strong carotid pulses and radial ____________[Blank 7]. JVP was 3 cm above sternal angle. Lungs were clear. There was bilateral leg _________[Blank 8] with venous changes in keeping with venous stasis dermatitis. Abdomen was soft, no evidence of ascites. No focal findings.

SUMMARY: Margaret has a history of poorly controlled type 2 diabetes and today is very difficult to assess her metabolic control as I do not have any information as she is not checking her blood ____________[Blank 9] and has not had lab work for several years. She tells me she is compliant with her plan.
She also has a history of coronary artery disease and currently has no exertional symptoms. There is no evidence of significant volume overload, but she has a history of recurrent admissions due to congestive heart failure preserved ejection fraction. She is currently not on ____________[Blank 10] and I do not think that needs to be restarted. She should continue on the combination of ACE inhibitors, beta-blockers, antiplatelets, and high intensity setting therapy.

PLAN: I asked her to do lab work and come back to see me to reassess if her treatment plan is adequate. We talked about the importance of quitting smoking. Smoking is associated with increased risk of further coronary events and progression of her peripheral _____________[Blank 11].
________________________________
Mary Johnstone, MD, Internal Medicine

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