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EndocrineMain101-110Q101A34-year-oldwomancomestothephysiciancomplainingofdiarrhea,weightloss,andfatigueoverthelastyear.Thediarrheaoccurs2or3timesdailyandisaccompaniedbycrampyabdominalpain.Shehasdiarrheaoccasionallyatnight.Shehasnotenesmusorbloodinthestool.Thepatientdescribesherstoolsasveryfoul-smellingandfloating.Shealsocomplainsofdiffusebonepain.Physicalexaminationisunremarkable.Laboratoryresultsshowhemoglobinof9.8g/dLwithameancorpuscularvolumeof72fL.Whichofthefollowingadditionalfindingswouldbeexpectedinthispatient?A.LowLowHighB.LowLowLowC.LowHighLowD.LowHighHighE.HighLowHighA101Correctanswer:AThispatientspresentationofayearoffoul-smeliingdiarrhea,weightloss,andfatigueisconsistentwithlikelysteatorrheaandmalabsorption.Steatorrheapreventsusualfatemulsificationanddisruptschylomicron-mediatedabsorptionofvitaminDintheintestine,resultinginvitaminDdeficiency.BecausevitaminDmediatesintestinalcalciumandphosphorusabsorption,patientsdevelophypocalcemiaanddecreasedphosphoruslevels.Thehypocalcemialeadstosecondaryhyperparathyroidismwithelevatedparathyroidhormonelevels.VitaminDdeficiencycanleadtoosteomalaciawithfindingsthatincludebonepainortenderness,muscleweaknessorcramps,gaitabnormalities,andincreasedfracturerisk.However,somepatientscanbeasymptomatic.Educationalobjective:Chronicgastrointestinaldisease(eg,sieatorrhea,celiacdisease)cancausevitaminDdeficiencyduetomalabsorption.Patientsusuallydevelophypocalcemia,lowphosphorus,andelevatedparathyroidhormone.Patientscanbeasymptomaticorcomplainofbonepainortenderness,muscleweaknessorcramps,andgaitabnormalities.Q102A29-year-oldnulligravidawomancomestothephysicianbecauseshehasnotmenstruatedfor6months.Menarchewasatage14.Shehadirregularperiodsfromage14-16handthentookoralhormonalcontraceptionuntillastyearwhenshegotmarried.Thepatientdoesnotknowherfamilyhistoryassheisadopted.Sheisahighschoolphysicsteacherandcoachesthecross-countryandtrackteams.Sherunsrecreationallyandeatsawell-balanceddiet.Shedoesnotdrink,smoke,oruseillicitdrugs.HervitalsignsarenormalandBMIis22kg/m2.Physicalexaminationshowsnoabnormalities.Urinepregnancytestisnegative.Whichofthefollowingisthemostappropriatescreeningtestforthispatient?A.HysteroscopyB.KaryotypeC.MRIofthepituitaryD.NofurtherworkupE.Serum17-hydroxyprogesieroneF.SerumprolactinG.UltrasoundofthepelvisA102Correctanswer:FThispatient'spresentationisconsistentwithsecondaryamenorrhea,definedastheabsenceofmensesfor3cyclesor6monthsinwomenwhomenstruatedpreviously.Whentheetiologyisunknown,patientsrequireastepwiseapproachinevaluationtoruleouttreatablecausesandaidinfuturemanagement(ChoiceD).Thefirststepisdetailedhistoryandexaminationfollowedbyapregnancytest.Apatient'smenstrualpatterns,amountofstressandexercise,medicalproblems,medications(eg,hormonalcontraception,dopamineantagonists),andfamilyhistoryofearlymenopauseshouldbeexplored.Theexaminationshouldassessforsignsofhyperandrogenismandothersystemicillnesses.Thispatienthasanegativepregnancytestandnoobviousexplanationforsecondaryamenorrheafromherhistoryandexamination.Therefore,prolactin,TSH.andFSHshouldbeorderedtodifferentiatebetweenthemostcommoncausesofsecondaryamenorrhea(hyperprolactinemia,thyroiddysfunction,prematureovarianfailure).(ChoiceA)Patientswithahistoryofuterineproceduresorinfectionmayhavescarringoftheuterinecavity(eg;Ashermansyndrome).Diagnosticworkupincludeshormonaltherapytotestfortheabilitytogrowuterineliningandhysteroscopytovisualizeuterineadhesions.Thispatienthasnohistoryofuterineproceduresorinfections.(ChoiceB)Prematureovarianinsufficiency(hypergonadotropichypogonadism)isdefinedasmenopausebeforeage40andcharacterizedbyelevatedFSHandlowestradiol.AkaryotypemaybeconsideredaspartoftheadditionalworkupifTurnersyndromeorfragileXsyndromeissuspected,asthesepatientsusuallyhaveovariandysfunction.However,thispatienthasnodysmorphicfeaturesorothercomorbiditiestowarrantkaryotypeevaluation.(ChoiceC)AnMRIshouldbeperformedinpatientswithpersistentlyelevatedprolactin(withorwithoutgalactorrhea),unexplainedheadaches,bitemporalhemianopsia,orotherconcerningneurologicfindings.Itisnotanappropriatescreeningtestinthispatient.(ChoiceE)Serum17-hydroxyprogesteroneiselevatedinnonclassiccongenitaladrenalhyperplasiadueto21-hydroxylasedeficiency,aconditionthatpresentswithhyperandrogenisminlatechildhood.Thispatienthasnofindingsofandrogenexcess(eg,malepatternhairdistribution,severeacne).(ChoiceG)Anultrasoundmaybeindicatedinpatientswithabnormalpelvicpain,pelvicorganenlargementormassesonexamination,orsignsofhyperandrogenism(eg.polycysticovarysyndrome,androgentumor),noneofwhichareseeninthispatient.Educationalobjective:Secondaryamenorrheaisdefinedastheabsenceofmensesfor3cyclesor6monthsinwomenwhomenstruatedpreviously.Initialevaluationincludesβ-hCGtoexcludepregnancy,followedbyserumprolactin,TSH,andFSH.Q103A7-year-oldboyisbroughttothephysicianforseverefacialacnethathasdevelopedoverthepastfewmonths.Hismothertriedtreatingitwithtopicalbenzoylperoxideandasalicylicacidfacewashwithnoimprovement.Shehasalsonoticedasignificantincreaseinherson'sgrowth,and