Question
47yo man presents to your clinic to establish care. He has a history of resistant hypertension, DMII, and sleep apnea. Vital signs are BP-159/101, HR-74, RR-16, O2-100%, and temp-98.9. Physical examination is also significant for multiple bruises on the lower extremities.
Cushing Disease/Syndrome
Other Known Aliases – hypercortisolism,
Definition – constellation of signs and symptoms due to excessive cortisol. This can be caused by several different mechanism that affect the hypothalamus-pituitary-adrenal axis:
Clinical Significance – This is one of the more common endocrinologic pathologies you will see in clinical practice. Classic presentation includes obesity, abdominal striae, “moon face”, “buffalo hump”, and hirsutism. Diagnosis is made by obtaining a 24-hour urine cortisol measurement
History – Named after Harvey Williams Cushing (1869-1939), who was an American surgeon and pioneering neurosurgeon of the early 20th century. He received his medical doctorate from Harvard Medical School in 1895. He completed his internship at Massachussets General Hospital and went on to do a surgical residency under William Halsted at John Hopkins Hospital. He trained under Kocher in England for several years before returning stateside and setting up practice in Baltimore. One of his greatest contributions to western medicine was his introduction of blood pressure management he learned from Scipione Riva-Rocci in Italy during his time in Europe.
At the age of 32, he achieved associate professor at Johns Hopkins Hospital and was placed in full charge of all surgery of the central nervous system. In 1912, he first described what would become his eponymous disease, but before he could publish it, he was called to serve during the first world war as the director for a field hospital in France for the British. It was during this appointment that he cared for a fatally wounded soldier by the name of Lt. Edward Revere Osler, son of William Osler. He formally published his findings on his eponymous disease in 1932 in an article entitled “The Basophil Adenoma of the Pituitary Body and Their Clinical Manifestations: Pituitary Basophilism”.
During his career, he was regarded as the world’s leading teacher of neurosurgeons for in the first decades of the 20th century and held professorships at Johns Hopkins Hospital, Brigham Hospital in Boston, Harvard Medical School, Yale School of Medicine, as well as honorary Fellowship in the Royal College of Surgeons. He also was awarded the 1926 Pulitzer Prize for Biography for his biography on the life of William Osler and was nominated for the Nobel Prize in Physiology or Medicine 28 times.
References
58yo male, with DMI controlled with insulin, has blood glucose measurements in the morning of 205-272 mg/dL for the past week. He reports that his evening blood glucose measurements before bed range from 103-127 mg/dL. What are two potential causes of these findings?
There are two potential causes of early morning hyperglycemia in a diabetic patient on insulin.
Other Known Aliases – posthypoglycemic hyperglycemia
Definition – rebounding hyperglycemia in the setting of a undetected hypoglycemic event
Clinical Significance – It had been hypothesized that patients who had a hypoglycemic event during sleep would have rebound hyperglycemia due to the protective mechanism of the body to counteract this. This would result in an undetectable change that would cause hyperglycemia in the morning. This hypothesis has been proven wrong by numerous studies, but it is still a favorite among endocrinologists to pimp their students on.
History – Named after Michael Somogyi (1883-1971), who was a Hungarian American biochemist and received his doctorate degree from the University of Budapest in 1914. He took a position as professor of biochemistry in 1922 at the Washington University’s Medical School in St. Louis, where later that year the first child with diabetes was treated with an insulin prepared by Somogyi himself. His career work revolved around diabetes and theorized that insulin itself could causes unstable diabetes. He published this paper describing the phenomenon that bears his name in 1938 in the Weekly Bulletin of the St. Louis Medical Society entitled “Insulin as a cause of extreme hyperglycemia and instability”. He also went on to develop the test for serum amylase to help diagnose acute pancreatitis. Dr. Somogyi died from a stroke on July 21st, 1971.
References
58yo male, with DMI controlled with insulin, has blood glucose measurements in the morning of 205-272 mg/dL for the past week. He reports that his evening blood glucose measurements before bed range from 103-127 mg/dL. What are two potential causes of these findings?
Other Known Aliases – Autoimmune hyperthyroidism
Definition – Hyperthyrodism caused by antibodies that stimulate T3/T4 secretion. The most common antibodies are thyroid-secreting hormone (TSH) and thyrotropin receptor antibody (TRAb).
Clinical Significance – Classic clinical manifestations of hyperthyroidism include thyromegaly, ophthalmaopathy, resting tremor, palpitations, weight loss, heat intolerance. For more in depth analysis of hyperthyroidism, see my 2017 talk at ASPA here.
History – Named after Robert James Graves (1796-1853), who was an prolific Irish physician, surgeon, and educator. He was named Regius professor of the Institute of Medicine in Trinity College, founded the Dublin Journal of Medical and Chemical Sciences, and was a an early adopter of clinical bedside rounding and teaching with medical students. Dr. Graves wrote a routine clinical lecture series in the London Medical and Surgical Journal and first described a young female patient with ophthalmopathy and goiter in 1835. Dr. Armand Trousseau then published the collection of these articles in 1864 entitled “Clinical Lectures on the Practice of Medicine” and gave him this eponym. Another contribution of Dr. Graves was the creation of the second hand on watches to time pulses and the practice of providing food and water with patients with a fever, instead of the common practice of withholding nourishment.
References
References
Parathyroid Hormone (PTH)
Parathyroid hormone (PTH) is created and stored in the parathyroid glands and is mainly secreted in response to low serum ionized calcium levels.
PTH increases serum calcium by 3 main mechanisms:
Causes of Parathyroid Dysfunction
Signs and Symptoms of Parathyroid Dysfunction
Laboratory Screening
4 main laboratory studies to help differentiate the different causes of parathyroid dysfunction:
Hypercalcemia Work-up
Management
References
What are the indications for high-intensity statin therapy for hyperlipidemia?
New joint guidelines were released in 2013 by ACC/AHA on the management of hyperlipidemia. In these guidelines, there are 3 criteria for high intensity statin therapy:
2013 ACC/AHA Hyperlipidemia Guidelines
What are the drugs and dosing for high-intensity statin therapy?
There are only 2 medications that have been studied that are recommended for high-intensity statin therapy:
2013 ACC/AHA Hyperlipidemia Guidelines
Knowmedge
Reference
PAINE Podcast and Medical Blog 