Week 29
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Quiz 29 Context:
A 70-year-old
female presents as a new patient with a complaint of painful joints,
specifically in her shoulders and knees. These symptoms have been
present for several years and she has self-medicated with NSAIDS
prior to this evaluation. She also reports frequent headaches,
fatigue, deteriorating vision, and numbness in her hands.
The patient
reports a past medical history significant for hypertension .
The family history is significant for lung cancer in her father
and a sister. The patient is a retired school teacher; she does
not smoke, does not use alcohol, and is married with 3 adult children.
Physical examination
reveals a female patient in no distress. Vital signs reveal a
temperature of 37.4 degrees Celsius, heart rate 78 bpm, blood
pressure 156/92 mmHg. The exam is notable for a diffuse thickening
of the soft tissues, coarse facial features and a large furrowed
tongue, and a systolic ejection murmur with an S4. The hands are
large and moist, and Tinel's and Phalen's signs are positive.
Examination of the shoulders and knees reveals signs consistent
with osteoarthritis.
The patient's
hands, as well as her current and previous footwear, are shown
above.
Sorry, that is not the most likely answer. Try Again.
b. Excellent!
This patient presents with a spectrum of clinical characteristics consistent with acromegaly, a condition caused by excess secretion of growth hormone, typically from a tumor located at the pituitary gland.
You have correctly identified this week's Image of the Week. Now test your knowledge of other aspects of the pituitary disorders. Do you know…
…the symptoms attributed to the mass effect caused by pituitary tumors? What is the most common visual field defect caused by these tumors, and how is it caused? What symptoms occur in the event of lateral extension of the mass into the cavernous sinuses? Which cranial nerve is most often affected by these tumors?
…the most common cause of hypopituitarism? What are some other causes? When hypopituitarism occurs secondary to a mass effect, there is a classic sequential loss of individual hormones - what is the order of loss and why? How often do pituitary microadenomas result in diabetes insipidus?
…the role for random growth hormone measurment in the diagnosis of a patient suspected of having acromegaly? What is IGF-1, and does it have a role in the evaluation of acromegaly? How does one perform an oral glucose tolerance test, and what is the normal response of growth hormone to such a test? Which cancer is associated with acromegaly?
The answers to these questions, and a concise review of the pathogenesis, diagnosis, and treatment of the complications of pituitary disorders, can be found here within the Cleveland Clinic Foundation Disease Management Project.
This history,
examination, and data are most consistent with which of the following
possibilities as a cause for the symptoms:
- A pancreatic tumor
- A pituitary tumor
- An adrenal gland tumor
- A thyroid gland tumor
- A
lung tumor
