A 14-year-old female sees you for follow-up after hypercalcemia is found on a chemistry profile obtained during a 5-day episode of vomiting and diarrhea. She is now asymptomatic, but her serum calcium level at this visit is 2.75 mmol/L. Her aunt underwent unsuccessful parathyroid surgery for hypercalcemia a few years ago.
Which one of the following laboratory findings would suggest a diagnosis other than primary hyperparathyroidism?
Correct Answer A:
Low urine 24-hour calcium levels or a low urine calcium to urine creatinine ratio is not characteristic of primary hyperparathyroidism. This finding should suggest familial hypo-calciuric hypercalcemia (FHH). Awareness of this condition is important to avoid unnecessary surgery.
→ Serum chloride (choice C) tends to be high normal or mildly elevated.
→ Alkaline phosphatase (choice D) may be elevated in more severe cases, while serum phosphate levels (choice B) tend to be low.
→ The parathyroid hormone level (choice E) may be mildly elevated. Parathyroid hormone is elevated in hyperparathyroidism.
The physician counseling a 4-year-old child about the death of a loved one should keep in mind that children in this age group:
Correct Answer B:
Children from the ages of 2 to 6 often believe they are somehow responsible for the death of a loved one. The emotional pain may be so intense that the child may react by denying the death, or may somehow feel that the death is reversible. If children wish to attend a funeral, or if their parents want them to, they should be accompanied by an adult who can provide comfort and support. Telling a child the loved one is asleep or that he or she “went away” usually creates false hopes for return, or it may foster a sleep phobia.
A 16-year-old male presents with history of weight loss, abdominal pain and bloody diarrhea. Investigation shows a normal upper endoscopy, inconclusive abdominal x-rays and an ultrasonography report reveals the GI wall thickness about 3mm with several hypoechoic areas.
What is the most appropriate next step?
Correct Answer A: Crohn's disease is a chronic transmural inflammatory disease that usually affects the distal ileum and colon but may occur in any part of the GI tract. Symptoms include diarrhea and abdominal pain. Abscesses, internal and external fistulas, and bowel obstruction may arise. Extraintestinal symptoms, particularly arthritis, may occur.
Diagnosis is by colonoscopy and barium contrast studies. If initial presentation is less acute, an upper GI series with small-bowel follow-through and spot films of the terminal ileum is recommended. Treatment is with 5-aminosalicylic acid, corticosteroids, immuno-modulators, anti-cytokines, antibiotics, and often surgery.
A 4-year-old boy was brought to the hospital with confusion and seizures for the last two hours. While being evaluated he went into coma. According to his mother, he was fine until about 8 hours ago when he started complaining of feeling tired and nauseated. On examination, the child was in coma with Glasgow coma scale of 9 but he did not look ill and was not febrile. Severe bradycardia and hypotension were found. His mother recalls that she saw him playing with her beta-blocker bottle this morning. Although she does not remember the number of the tablets left in her bottle, she was almost sure that many of the tablets were missing. Blood glucose was found to be low and IV glucose was given.
The best antidote to be given to this child is:
Correct Answer C: Glucagon (choice C) is the antidote of choice for beta-blocker poisoning because it increases intracellular levels of cyclic AMP independent of the beta receptors that are blocked.
→ Epinephrine (choice A) and norepinephrine (choice B) are not effective antidotes for beta-blocker poisoning. Beta-blockers are drugs that bind to beta-adrenoceptors and thereby block the binding of norepinephrine and epinephrine to these receptors.
→ Prehospital administration of charcoal (choice D) is indicated when there are no contraindications and the patient is alert and cooperative.
→ Atropine (choice E) can improve the bradycardia but it does not alleviate the hypotension, hypoglycemia or the CNS effects.
Glucagon can enhance myocardial contractility, heart rate, and atrioventricular conduction; many authors consider it the drug of choice for beta-blocker toxicity. Because a glucagon bolus can be diagnostic and therapeutic, the clinician can empirically administer glucagon and check for a response.
A 17-year-old gymnast is training for one year and is scheduled to participate in a national gymnastics event in three weeks. She presents for pre-participation physical evaluation. She reports that her last menstrual period was six months ago; prior to which she used to have normal menstruation. She had reported having missed periods for two months to her family physician, who had reassured her that amenorrhea in an athlete, is a normal phenomenon.
She has lost 7 kilograms in past 12 months, which she says is because of six hours of daily training. She reports that generally she restricts consumption of food containing carbohydrates and fats; but occasionally binges on Pizza and ice cream. However, she manages to keep her weight under control by using laxatives.
On examination:
Which one of the following conditions, if present, will indicate diagnosis of female athlete triad in this case?
Correct Answer D:
Female athlete triad is a syndrome of three interrelated conditions associated with intense athletic training and energy deficient diet. It is defined as presence of disordered eating, amenorrhea and osteoporosis (choice D). The patient described in the stem has disordered eating as suggested by food restriction and use of laxatives. She also has amenorrhea.
Unbalanced diet and inadequate caloric intake relative to body needs are predisposing factors for amenorrhea. Amenorrhea in athletes is due to hormonal imbalance caused by changes in hypothalamus and decreased levels of oestrogen. Osteoporosis develops due to low oestrogen levels and other hormonal changes.
Amenorrhea is common in athletes. However, it should not be discounted as a benign consequence of athletic training. Risk of bone loss increases with the duration of amenorrhea. A dual energy X-ray absorptiometry (DEXA) scan should be ordered in athletes with amenorrhea lasting at six months or more to detect osteoporosis.
→ Anemia (choice A) is commonly associated with disordered eating. However, female athlete triad may be present in absence of anemia.
→ Polycystic ovary syndrome (choice B) is a common disorder associated with amenorrhoea. It is characterized by hyper-androgenic state and anovulation. It does not occur with higher frequency in female athletes and is not a part of female athlete triad.
→ Severely disordered eating associated with self-induced vomiting and purging can cause electrolyte imbalance and cardiac arrhythmia (choice C). However, presence of these conditions is not essential for diagnosis of female athlete syndrome.
→ Depression (choice E) and anxiety are common associations with disordered eating in women. This is thought to be due to low self-esteem and associated compulsive behavior. It is not a part of female athlete triad.
Key point:
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