A 31-year-old female complains about frequent urination to her gynecologist.  Her gynecologic history is notable for previous irregular and infrequent periods since middle adolescence.  She had one uncomplicated pregnancy, delivering an 8#9Oz boy when she was 30-years-old.

Her past medical history is positive for mild hypertension treated with hydrochlorothiazide and acne which has responded to oral contraceptives.  Physical exam shows an overweight (BMI 29) African American female with normal vitals signs with blood pressure of 138/88.  Skin exam shows thickened darker skin across the neck.  Fasting labs show serum glucose 189, normal electrolytes, liver tests and creatinine, total cholesterol of 195, LDL 124, HDL 30 and triglycerides of 305.  Repeat fasting glucose is 160.

1. What are the most likely diagnoses and how do the pathophysiology of these relate to this patient’s presentation?  Would the same diagnosis be likely if serum glucose was 450 and bicarbonate 6?
   
   
2. What are immediate and long term treatment goals: glycemic, lipids, blood pressure?
   
   
3. What therapies should be recommended or changed?
   
   
4. What types of metabolic emergencies occur in patients with diabetes?

Three weeks after her six week postpartum check-up a 22 year-old female calls you(her gynecologist) and complains of heart racing, shakiness and insomnia.  You take a brief history over the phone, order labs and arrange a clinic visit.  Before entering the room, you review her chart and note serum chemistries and CBC were normal, TSH is undetectable and vitals signs show a pulse of 116 but are otherwise normal. 

1. As you enter the room, what is your differential diagnosis and what historical and physical findings will you explore to further define the diagnosis?
   
   
2. What additional laboratory and imaging studies might further assist your assessment?
   
   
3. What potential therapies could you offer and how would these treatments differ based on diagnostic findings? How might therapy change with time?

A fifty-four year old male smoker you follow for diet-treated diabetes has an elevated calcium of 10.8 (8.4-10.2) on routine labs.  He reports feeling well.  On repeat studies, calcium is 10.6, albumin 4.0 (3.5-4.5), phosphorus 2.8 (2.6-4.5), and chloride 109 (101-111).

1. What further historical, clinical and physical findings are pursued?  What other labs would assist evaluation?
   
   
2. Additional labs show iPTH of 64 (10-60) and urine calcium excretion is 320mg in 24 hours; what does this indicate?  What if iPTH has <10.
   
   
3. What therapies are available for hypercalcemia?  Is there a role for surgery?
   
   

A sixty four-year-old man undergoes evaluation with an abdominal CT scan after complaining of abdominal pain after a MVA.  CT scan is normal except for 2 cm nodularity in the left adrenal gland.  Past medical history is positive for hypertension treated with amlodipine and diabetes treated with metformin.  Physical exam is negative expect for obesity; vitals are normal and there are no striae, bruises, tremors, or excessive sweating.

1. How unusual is the finding of an adrenal nodule and what are the most likely causes of this lesion?  What radiographic findings help to refine this differential?
   
   
2. What further historical and laboratory data are important to assessing this patient’s adrenal nodule?
   
   
3. Discuss hypersecretory states in relation to above.  Review adrenal insufficiency (time permitting).

An 85- year-old lady complains of low back pain.  Lumbar spine films were normal except for “osteopenia,” prompting further evaluation.  A DEXA shows bone density of at the L1-L4 spine with associated T-score of -2.5 and Z-score of 0 and , and a bone mineral density of in the femoral neck with associated T-score -2.0 and a z-score  and Z-score of +0.5.  Labs show a normal calcium of 9.0, normal phosphorus of 3.0 and 25-hydroxyvitamin D of 22 ng/ml (20-56).

1. Are this patient’s DEXA findings abnormal and what is the likely diagnosis?
   
   
2. What is the differential diagnosis.  Discuss different types of osteoporosis, including secondary causes, and osteomalacia.
   
   
3. Review the role of bone density and other factors in assessing fracture risk
   
   
4. Briefly overview therapeutics.

A 36-year-old woman is evaluated after MVA with LOC.  Initial labs show serum glucose of 32mg/dl.  The patient recovers consciousness with intravenous dextrose.  Head CT is negative.  On interview, she reports LOC occurred before her accident.  She relates recurrent episodes of sweatiness, tingling and confusion occurring with increasing frequency over the last year.  The episodes improve with eating.  She is admitted for observation and 4 hours later is found by her nurse to be irritable and confused.  You order a serum glucose level and other labs.

1.  Describe Whipple’s triad?  Does it apply to this patient?
   
   
2.  Discuss more common causes of hypoglycemia.
   
   
3.  What other diagnostic studies would help in assessing this patient’s hypoglycemia?
   
   
4.  Review insulinoma, including localization and therapeutic issues.