PHM 6165

Session 4: Endocrinology I
Dr. Fricker

Case 1:

Julia is an 18-year-old female college student who returns home from college at for Christmas break.
She is a college scholarship swimmer who drove home the previous day with her mother. She has
completed her first semester in good standing, even though she had the flu over Thanksgiving break.
Since Thanksgiving, she has noticed an increased thirst, some nocturia and increased appetite, along
with a 4 lb weight loss. She attributed these symptoms to anxiety over her final exams. The thirst and
urination continued during the return home. Due to this, she is being seen today by her physician for a
‘work in’ visit.

1. What is the most likely explanation for these signs and symptoms in Julia?
A. Uncontrolled type I diabetes mellitus
B. Uncontrolled type II diabetes mellitus
C. Hyperthyroidism
D. Hypothyroidism
E. Major depressive disorder

2. What subjective information SUPPORTS this diagnosis?

3. You would like further evidence to rule in (or out) your diagnosis. What objective information
could you look for with Julia?
PHM 6165
Session 4: Endocrinology I
Dr. Fricker

Case 2:

Sandra Betts is a 47-year-old female who presents for a follow-up appointment at your clinic. Sandra’s
past medical history is significant for type 2 diabetes, hypertension, high cholesterol and a broken leg 4
years ago. SB presents today complaining that she has been excessively tired, has the chills and she
noticed some hair loss over the past month. She also reports she has gained 9 lb. in the past 3 months.
SB tells you she takes metformin (diabetes), insulin (diabetes), naproxen (pain as needed), losartan
(blood pressure), and atorvastatin (cholesterol). Her blood pressure today is 124/68 mm Hg.

4. List 2 possible health issues going on with SB

5. What subjective information SUPPORT these diagnoses?

You decide to draw additional labs and they come back with: A1c is 6.5% (last 6 months ago at 6.8%).
TSH of 11.1 μU/mL (reference: 0.5 to 5.5 μU/mL) and FT4 of 0.3 ng/dL (reference: 0.6 to 2.1 ng/dL).

6. Are you still confident in your response to question 4? Are you able to better narrow it down to
one diagnosis? If so, what objective information SUPPORTS your diagnosis?

7. Which of the following is the most pertinent issue to address at this time?
A. She does not have any issues at this time that need treated
B. She needs her diabetic medications adjusted to control her hyperglycemia and help lower
her A1C
C. She has hypothyroidism and needs treatment
D. She has hyperthyroidism and needs treatment
E. She needs an antidepressant at this time

8. If SB had some type of a thyroid problem and had to be put on levothyroxine, when would it be
most appropriate to recheck her TSH and Free T4?
A. 1-2 weeks
B. 3-4 weeks
C. 6-8 weeks
D. 12-16 weeks
E. 6 months
PHM 6165
Session 4: Endocrinology I
Dr. Fricker

Case 3:

Leslie is a 43 year-old female who shows up at the clinic. Upon speaking with the patient, you find out
that none of her siblings or parents have diabetes, but her great uncle did. She tells you she gave birth
to 3 children (boy- 8 lbs, boy- 8 lbs 8 oz, girl- 9 lbs, 2 oz), and that she had gestational diabetes during
her third pregnancy nine years ago. Her cholesterol labs show all normal values, except an abnormally
low HDL. Her fasting blood glucose at the clinic today is 152 mg/dL. Per her vitals, she has a BMI of 33
and a waist circumference of 45. She says she goes for walks often in her neighborhood.

9. Which of the following most appropriately describes her current problem?

A. Hypothyroidism
B. Hyperthyroidism
C. Pre-diabetes
D. Type I diabetes
E. Type II diabetes

10. What subjective information SUPPORTS this diagnosis

11. What objective information SUPPORTS this diagnosis

12. Should Leslie be screened for diabetes? Why?

Leslie got her A1c drawn and it is 8.1%. She purchases a continuous glucose monitor and returns to the
clinic in 1 month. She shows you her results:
30 days
Very High (>250) 9%
High (181-250) 26%
Target Range (70-180) 59%
Low (54-69) 4%
Very Low (<54) 2%

13. Is Leslie’s diabetes controlled at this time?

14. What would be an appropriate A1c goal for Leslie? What factors influence this decision?
PHM 6165
Session 4: Endocrinology I
Dr. Fricker

15. What is Leslie’s fasting blood glucose and post prandial blood glucose goal, per ADA guidelines?
What are her TIR, TAR, and TBR goals?

16. She tells you sometimes she thinks she has low blood sugar because she feels sweaty after
exercising. What questions can you ask Leslie to better assess if she is truly having
hypoglycemia?

17. What would you recommend for her low blood sugar?
A. ½ cup of diet soda
B. 1 juice box
C. 1 glucose tablet – 5 gm
D. 1 Hershey’s bar
E. 1 bottle (16 oz) of soda

18. What is the appropriate screening recommendations for Leslie?

A. Blood pressure at every other primary care visit
B. Dilated and comprehensive eye exam starting 5 years after her diagnosis
C. Urine albumin-to-creatinine ratio (UACR) every 3 years
D. Dentist annually
E. Annual comprehensive foot exam every year

Leslie comes back a couple of years later and the doctor wants to start her on Lantus®, an insulin. He
takes a 24-h urine collection which reveals a urinary albumin excretion rate of 250 mg/day.

19. What does her urine albumin excretion rate tell you?
A. It doesn’t tell you anything, as it can only be used in patients with type I diabetes
B. It is normal
C. She is showing signs of moderately increased albuminuria indicating liver damage
D. She is showing signs of moderately increased albuminuria indicating kidney damage
E. Nothing on its own- a urine glucose test must also be done to diagnose albuminuria
PHM 6165
Session 4: Endocrinology I
Dr. Fricker

Case 4:

Amy is a 32-year-old female who presents for an annual appointment at your primary care clinic. Amy’s
PMH includes generalized anxiety disorder and hyperlipidemia. Amy states that for the last several
months she has been sweating excessively and frequently feels hot despite the rest of her family being
comfortable. Additionally, Amy mentions that she’s experienced some recent racing heart rate. Amy’s
BP today is 122/96 and since her last annual visit she has lost 15 lbs which comes as a surprise to Amy as
she has not been trying to lose weight and even feels that she has recently had a larger than normal
appetite.

20. Which of the following most appropriately describes her current problem?
A. Hypothyroidism
B. Hyperthyroidism
C. Pre-diabetes
D. Type I diabetes
E. Type II diabetes

21. What subjective information SUPPORTS this diagnosis?

22. What objective information SUPPORTS this diagnosis?

23. What other symptoms might you consider asking Amy about to confirm the suspected problem?

You decide to draw labs before proceeding with treatment and the results indicate an A1c of 5.2%, SCr
of 0.8 mg/dL (reference 0.6 to 1.1 mg/dL), TSH of 0.1 μU/mL (reference: 0.5 to 5.5 μU/mL) and FT4 of
6.2 ng/dL (reference: 0.6 to 2.1 ng/dL).

24. Do the laboratory findings support the conclusion reached in question 20? If so, what labs
support this diagnosis?