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Case

Presentation
Course: Endocrinology
Module: Weight Gain/Moon Facie,
Weakness/Hematuria

Presented by:
Bangsaja, Al-Disar B.
Caluang, Calingalan H.
Danial, Katheya S.
Garcia, Ronel Glen S.
Genturalez, Dwight Christian D.
Macabada, Yasmin B.
Maneja, Marco Louie G.
Montalban, PJ-Purple Liz C.
Quimson, Kim Faye E.
Santos, Czerahlee Jaine L.
Group 2
March 11, 2019
Date of Admission: February 20, 2019
Date of Interview: February 25, 2019
Time of Interview: 12:30 PM
Place of Interview: ER Ward, ZCMC
Source of Information: Patient
Reliability: 95%

PERSONAL DATA

Patient R. A., is a 46 year old, Zamboangueno, Filipino male from Mampang,


Zamboanga City. He is single, a gardener who is an elementary
undergraduate and a practicing Christian.

CHIEF COMPLAINT: Progressive Weight Gain

HISTORY OF PRESENT ILLNESS:

6 years prior to admission, patient complained of recurrent joint pain noted


prominently on his left knee, ankles and toes and was usually asymmetric.
He described it as severe, excruciating pain unrelated to activity and would
occur abruptly. For each recurring episode, he would self-medicate with
Dexamethasone of unrecalled dosage reaching approximately 10 tablets per
week which provided temporary relief. Symptoms persisted indefinitely.
2 years prior to admission, patient noticed his abdomen becoming distended
with swelling of the face, neck and trunk, as well as dizziness. No
constipation, abdominal pain and fever were reported. Symptoms prompted
consult at the OPD of ZCMC where he was advised to undergo an abdominal
ultrasound and several other laboratory tests. Patient later refused because
of financial constraint. He was then sent home with prescribed medications
such as anti-hypertensives and diuretics. Distention and swelling reportedly
subsided with medication intake.
Patient eventually became noncompliant to his prescribed medications and
failed to return for follow-up. He then started to experience weakness and
easy fatigability. No further medical consultation was done. Joint pain would
recur despite continuous self-medication of dexamethasone.
5 days prior to admission, patient noted that his face became unusually
round with his eyes puffy and skin flushed. 2-pillow orthopnea and dyspnea
were also reported. There was no chest pain. His body became weaker and
was accompanied by fever although undocumented. Weight gain progressed
further which prompted his family to bring him to ZCMC where he was
subsequently admitted.

PAST MEDICAL HISTORY


Last 2010, he was diagnosed with hypertension but was noncompliant
to his maintenance of Losartan of unrecalled dose once a day. He denies of
having chronic illnesses such as asthma, diabetes mellitus, renal failure and
liver diseases. He has no history of previous hospitalization was reported. He
has not undergone any surgical operation and previous blood transfusion.
There are no known allergies to food and medication.

FAMILY HISTORY
Strong family history of hypertension was reported on his maternal
side while arthritis and cardiac problems were noted on his paternal side.
There are no other heredofamilial diseases such as asthma, Diabetes
Mellitus, adrenal diseases and cancer.
PERSONAL AND SOCIAL HISTORY
Patient is living together with his common law wife and four (4)
children. He had a previous live in partner and had 1 child with her. He is
non-smoker and admits on drinking alcohol every night with an unrecalled
amount per occasion. He started drinking in the year 2000 and ceased in the
year 2010. His usual meal intake includes rice, dried fish, fish and
vegetables. He spends most of his time at home gardening.

REVIEW OF SYSTEMS

GENERAL (-) weight loss (+) changes in clothing fit

SKIN (-) pruritus (-) easy bruising


HEAD, EYES, EARS, Head: (+) Headache (+) lightheadedness (-) head injury
NOSE, THROAT Eyes: (-) pain
(HEENT) Ears: (-) earaches
Nose and sinuses: (-) Frequent colds (-) nasal stuffiness
(-) epistaxis
Throat: (-) odynophagia (-) dysphagia (-) hoarseness

NECK (+) Nape pain (-) stiffness

RESPIRATORY (+) Dyspnea (-) Cough (-) Hemoptysis (-) PND

CARDIOVASCULAR (+) palpitations (-) pleuritic chest pain or discomfort (-) Chest
pain

GASTROINTESTINA (-) nausea and vomiting (-) loss of appetite (-) diarrhea (-)
L constipation
(-) rectal bleeding (-) abdominal pain

PERIPHERAL (-) numbness


VASCULAR

URINARY (-) dysuria (-) hematuria (-) discharges (-) polyuria (-) nocturia
(-) kidney or flank pain

PERIPHERAL (-) leg cramps (-) tingling sensations (-) varicose veins (-) past
VASCULAR. clots in the veins

MUSCULO- (+) Muscle Weakness


SKELETAL

NEUROLOGIC (+) irritable and emotional lability

ENDOCRINE (+) Polyuria (+) Polydipsia, (-) Polyphagia, (-) Excessive


sweating, (-) Heat/cold intolerance

HEMATOLOGIC (-) blood transfusions, (-) easy bruising

PSYCHIATRIC (-) nervousness, (-) memory change


PHYSICAL EXAMINATION:

PHYSICAL EXAMINATION

General Survey Patient R.A., is a middle-aged man and is weak looking.


He is lying on bed, awake, conscious with poor eye
contact. He is alert, responsive and coherent.

Vital Signs BP: 160/100 mmHg


Temperature: 37.1 C
Respiratory Rate: 35 breaths/min
Pulse Rate: 102 beats/min
O2 sat: 96% at room temperature

Height-5’4
Weight-56 kg (2017)
BMI- 21.3

Weight-76kg (2019)
BMI- 28.7 (Overweight)

Skin Complexion is fair with irregularly shaped ecchymosis


distributed on both of his upper and lower extremities.
No jaundice, cyanosis and hematoma. No body tattoo.

Skin is dry, scaly and friable. It is warm to touch with


good skin turgor

HEENT HEAD: Normocephalic and atraumatic with even


distribution of hair of normal texture. His face is rounded
and plethoric. No lumps
EYES: Anicteric sclerae with pink palpebral conjunctiva
and periorbital edema. Pupils are equally round reactive
to light and accommodation with intact extraocular
movements.
EARS: No purulent discharges, external deformities and
tenderness
NOSE: Nasal mucosa is dry, septum midline, no sinus
tenderness and discharges.
THROAT/MOUTH: moist pinkish buccal mucosa, tongue
at midline, no lesions and deformities. Dental carries
present at lower molars. no dentures, no sores or
exudates, no tonsilopharyngeal congestion.

Neck Buffalo hump with no acanthosis nigricans, no


deformities, trachea is midline, no palpable masses, no
lymphadenopathies, no tenderness or swelling.
JVP of 3cm at 30-degree angle bed elevation

Chest/Lungs and Patient’s thorax is symmetric with good excursion. No


Back deformities, no lesions, no hematoma, no gynecomastia,
no retractions, no lumps
no tenderness, normal tactile fremitus from both upper
and lower chest zones, resonant on percussion, clear
breath sounds, no crackles, no wheezing

Heart Adynamic precordium with LV apex and PMI noted at 5th


ICS midclavicular
No heaves and thrills
Regular Rate and rhythm, no extra heart sounds

Abdomen Abdomen is protuberant with purple broad striae, no


scars, no lesions, no spider nevi, no caput medusae, no
bulging flanks
normoactive bowel sounds
tympanitic on all quadrants, liver span of 6 cm at
midclavicular line, no masses, no tenderness, no fluid
wave, no shifting dullness, no splenomegaly.

Genitalia Not assessed

Rectal Not assessed

Extremities Brittle and dirty nails, no clubbing


swollen right hand on IV site
55x 20 mm poor healing wound on the left index finger
Swollen, tender and warm left knee and ankle
Grade 2 edema on both lower extremities more
prominent on the left foot.

Peripheral Good, strong, and bounding bilateral peripheral pulses.


Vascular Capillary Refill Time <2 seconds
Neurologic Oriented to time and place

CLINICAL IMPRESSION: Iatrogenic Cushing’s Syndrome secondary to


chronic exogenous steroid use; Essential Hypertension; Chronic Gouty
Arthritis in Flare; Infected Wound 2nd digit left hand

BASIS FOR IMPRESSION

Iatrogenic Cushing’s Syndrome

History: Physical Exam:


 6-year history of steroid use V/S: BP: 160/100 mmHg
 Progressive Weight gain (94%) PR: 102 bpm
 Hypertension (82%) RR: 35 bpm
 Progressive swelling of face, neck
and trunk Skin:
 Weakness ang easy fatigability Ecchymoses of irregular sizes
 Polyuria (23%) (65%)
Dry, scaly and friable
 Polydipsia (23%)
55x20 mm Infected Wound 2nd
 Mood changes (66%)
digit left hand
 Irritability (66%)
HEENT:
Facial plethora, rounded face
(moon facie), periorbital edema

Neck: Buffalo hump

Abdomen: Protuberant abdomen


with broad purple striae (67%)

Extremities:
Brittle nails
Edema on lower extremities (62%)

Essential hypertension
History: Physical Exam:
 Prevalence of 90% V/S: BP – 160/100 mmHg
 Family History – maternal side
 Diagnosed with hypertension
since 2010
 Occasional headaches and
lightheadedness
 Palpitations
 Nape Pain

Chronic Gouty Arthritis in Flare

History: Physical Exam:


● Common in middle age
● Common in Male Swollen, Tender and warm left
● History of Chronic Alcoholism knee and ankle
● History of joint pain since 2013
Grade 2 edema on both lower
● Family History of Arthritis extremities more prominent on the
left knee and ankle

Infected wound

History Physical Exam


 Nonhealing wound that lasted for 55x22 mm wound with pus and
9 days redness on surrounding skin

DIFFERENTIAL DIAGNOSIS:

Dx Rule-in Rule-out

Progressive weight (-) ascites


gain
Liver Cirrhosis (-) Jaundice
previous history of
secondary to Chronic
Alcoholism chronic alcoholism (-) caput medusae
(-) spider nevi
abdominal distension (-) hematemesis
(-) clubbing of nails
easy fatigability

bipedal edema

Progressive weight (-) PND, (-) rales,


gain Easy Fatigability normal JVP, no S3
Congestive Heart 2 pillow orthopnea gallop, no
Failure Hypertension hepatomegaly, no
Periorbital edema crackles
Tachycardia Normal JVP
Ankle edema (-) ascites

*kidney disorder

Progressive Weight (-) cold intolerance


Gain (-) hair loss
Hypothyroidism Easy Fatigability (-) bradycardia
Dry skin (-) no constipation
Dyspnea (-) no difficult
Muscle Weakness, (-) concentration
Puffiness in face,
hands, and feet
peripheral edema
PARACLINICALS:

1. 24-hour urine free cortisol excretion


a. Positive test greater than 3x the upper limit (normal: >
140nmol/day)
2. Low dose dexamethasone suppression test
a. Plasma cortisol of > 50nmol/L at 8-9am after 1mg
dexamethasone at 11pm
3. Midnight salivary cortisol
a. >5nmol/L
4. Serum Electrolytes
a. Assess serum disturbance such as hypokalemia
5. Serum Uric Acid
a. Hyperuricemia defined >7mg/dL (men)
6. Fasting lipid profile
a. Asses risk factors

MANAGEMENT

1. Admit to ward
2. Pharmacologic:
a) Cushing’s – oral agents
i. metyrapone – 500mg TID maximum 6g/day
ii. and ketoconazole- 200mg TID maximum 1200mg/day
b) Antihypertensive
i. ACE inhibitors (Captopril 6.25-50mg OD)
ii. ARBS (Losartan 25-100mg OD) – if ACE intolerant
b. Anti- Gout: Colchicine - 1mg loading dose within 12 hrs. followed
by 1 hour later until flare subside

c. NSAIDS – Celecoxib 400mg BID

Urate Lowering Therapy – Allopurinol


Initial dose: 100mg/day increased at 100 mg increments after 2 to 3
weeks

Lifestyle/ Diet Modification:


 Control of body weight
 Avoidance/ limitation of ethanol consumption
 Increased water intake (at least 8 glasses per day unless contraindicated)
 DASH diet
 Low impact and aerobic exercises 45 minutes, 4x per week

Moon Facie Abdominal Distention/ Wide


Purple Striae
Infected Wound Edema

Swollen Left Knee

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