SCENARIO 1
A 67-year-old Caucasian woman was brought to the clinic by her son who stated that his mother had become slightly confused over the past several days. She had been stumbling at home and had fallen once but was able to ambulate with some difficulty. She had no other obvious problems and had been eating and drinking. The son became concerned when she forgot her son’s name, so he thought he better bring her to the clinic.
PMH-Type II diabetes mellitus (DM) with peripheral neuropathy x 20 years. COPD. Depression after death of spouse several months ago
Social/family hx – non contributary except for 30 pack/year history tobacco use.
Meds: Metformin 500 mg po BID, ASA 81 mg po qam, escitalopram (Lexapro) 5 mg po q am started 2 months ago
Labs-CBC WNL; Chem 7- Glucose-92 mg/dl, BUN 18 mg/dl, Creatinine 1.1 mg/dl, Na+120 mmol/L, K+4.2 mmol/L, CO237 m mol/L, Cl-97 mmol/L.
The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH).

Question: Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH.

SCENARIO 2

A 43-year-old female presents to the clinic with a chief complaint of fever, chills, nausea and vomiting and weakness. She has been unable to keep any food, liquids or medications down. The symptoms began 3 days ago and have not responded to ibuprofen, acetaminophen, or Nyquil when she tried to take them. The temperature has reached as high as 102˚F.
Allergies: none known to drugs or food or environmental
Medications-20 mg prednisone po qd, omeprazole 10 po q am
PMH-significant for 20-year history of steroid dependent rheumatoid arthritis (RA). GERD. No other significant illnesses or surgeries.
Social-denies alcohol, illicit drugs, vaping, tobacco use
Physical exam: Thin, ill appearing woman who is sitting in exam room chair as she said she was too weak to climb on the exam table. VS Temp 101.2˚F, BP 98/64, pulse 110, Resp 16, PaO2 96% on room air.
ROS negative other than GI symptoms.

Based on the patient’s clinical presentation, the APRN diagnoses the patient as having secondary hypocortisolism due to the lack of prednisone the patient was taking for her RA secondary to vomiting.

Question: Explain why the patient exhibited these symptoms?

SCENARIO 3

A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had about of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved.
The APRN examining the patient orders a Chem 7 which revealed a serum Ca++ of 13.1 mg/dl. The APN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis.

Question:
What is the role of parathyroid hormone in the development of primary hyperparathyroidism?

SCENARIO 4
A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved.

The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis.

Question: Explain the processes involved in the formation of renal stones in patients with hyperparathyroidism.

SCENARIO 5
A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved.
The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis.

Question: Explain how a patient with hyperparathyroidism is at risk for bone fractures.

SCENARIO 6
A 64-year-old Caucasian female who is 4 weeks status post total parathyroidectomy with forearm gland insertion presents to the general surgeon for her post-operative checkup. She states that her mouth feels numb and she feels “tingly all over. The surgeon suspects the patient has hypoparathyroidism secondary to the parathyroidectomy with delayed vascularization of the implanted gland. She orders a Chem 20 to determine what electrolyte abnormalities may be present. The labs reveal a serum Ca++ of 7.1 mg/dl (normal 8.5 mg/dl-10.5 mg/dl) and phosphorous level of 5.6 mg/dl (normal 2.4-4.1 mg/dl).

Question: What serious consequences of hypoparathyroidism occur and why?

SCENARIO 7
A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.
PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast-food store after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.

Question: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polydipsia.”

SCENARIO 8
A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.

PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast-food store after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.
Question: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polyuria.”

SCENARIO 9
A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.
PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.

Question: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polyphagia.”

SCENARIO 10
A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.

PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.

Question: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “weight loss.”

SCENARIO 11
A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.
PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast-food store after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.

Sample Solution