1.
Neurohypophysial Disorders
Case History
A 27-year old woman attended her GP's surgery complaining of a continuous unquenchable thirst. She
felt a constant need to drink water and consumed around 20 large glasses every day. She also kept
water beside her bed since she was woken every night by her thirst. She also needed to urinate very
frequently. On referral to an endocrine clinic it was found that her fasting serum glucose level was
normal and no glucose was detected in her urine. She was then given a water deprivation test in which
she was not allowed to drink but was asked to provide urine samples every hour. After the 11.00 am
sample had been taken she was given a dose of a modified form of vasopressin (DDAVP) as a nasal
spray. The osmolality of her urine samples were measured (a high osmolality representing concentrated
urine).
Patient’s response Typical normal person’s response
Time Urine osmolality Urine volume Urine osmolality Urine volume
9.00 130 175 620 95
10.00 158 180 850 70
11.00 204 140 1090 50
11.01 DDAVP administered
12.00 886 70 1180 40
Questions
1. What would you expect to happen to the osmolarity of urine during water deprivation test?
2. Why did the osmolarity of her urine rise after the administration of DDVAP?
3. What could be the underlying cause of her condition?
4. What further measurements could be made?
2. Diabetes Mellitus
Case History
Case 1
A 23-year old journalist presents with a 3-month history of weight loss. She drinks up to 3.5 litres
(water, tea, lemonade) a day and passes similar volumes of urine, and wakes up at night three times to
pass urine. There are no abnormal physical signs. Her urine has ++++ of glucose and ketones. Capillary
glucose was 23 mmol/l.
Notes
Age: 23 yr old
Polydipsia
Polyuria
Age < 30 yrs – T1DM, even though increase in prevalence of obesity has lead to earlier
development of T2DM
3 month history – rapid onset; more typical of T1
No abnormal physical signs – more typical of T2, but can be T1 as well
++++ glucose & ketones – urine DIP STICK test
o No ketones = yellow
o Ketones = green
o ++++ = completely green (+ is a scale of ketone presence in urine)
o T2DM – ketones not present in urine unless fasting
o This suggests lack of insulin = T1DM; GAD antibodies wipe out beta islets in pancreas
CG 23 mmol/l – hyperglycaemic
Role of insulin: activates- o GLUT 2 o GLUT 4 o Glycogen synthase
Questions:
1. What is the diagnosis?
2. Why does she have glucose in her urine and why is she passing so much urine?
3. Why is her plasma glucose high and what would her plasma insulin concentration be if we
measured it (but no need clinically)?
Case 2
A 58 year old bus driver presents with angina pectoris due to coronary artery disease. He is
overweight (Body Mass Index, BMI = 32 kg/m2). During investigation he is found to have a fasting
plasma glucose of 12 mmol/l (normal FPG < 6.0 mmol/l). He is started on a diet for his diabetes
Notes:
Angina pectoris – chest pain during activity
Questions:
1. What is the diagnosis and what (if we bother to measure it) is his plasma insulin concentration
likely to be?
2. What are the important features of his diet? How does energy restriction help?
3. Other advice to reduce chance of morbidity?
3. Thyroid Disorders
Case History
Case 1
A 25-year old lady who had recently undergone a divorce presented to her GP. She was upset about this
and wanted something to calm her down and help her to sleep. She had been very irritable for the last
18 months. On direct questioning she admitted to a history of palpitations, weight loss and sweating
over the past year. Two aunts had previously undergone neck operations and she had noticed a swelling
in her own neck over the past year.
On examination she had a fine tremor and looked thin. Her pulse was 112 beats per minute and her
blood pressure 106/70mm Hg. She had a swelling in her neck which moved with swallowing. It was soft,
extended symmetrically either side of the midline and was not tender to the touch. Her GP sent off a
blood sample to the hospital to obtain measures of thyroid activity.
Case 2
A 32-year old woman presented to her GP with progressive tiredness over the last 2 years since the birth
of her daughter. She wanted a vitamin preparation to give her more energy. She had been let go from
her job as a cashier in her local supermarket 6 months earlier because her throughput of customers had
slowed down so much. On direct questioning, she admitted to being constipated, intolerant of the cold
and one stone heavier than before the birth of her child. Her periods were now much heavier and
lasted longer than ever. There was no illness other than ischaemic heart disease in her family.
On examination she was pale, had an increased Body Mass Index (BMI) and appeared disinterested in
her GP’s questions. Her pulse was 54 beats per minute, and her blood pressure 110/75 mm Hg. She had
slow relaxing reflexes but there were no other abnormal findings on examination. Her GP sent off a
blood sample to the hospital to obtain measures of thyroid activity.
Questions:
1. Which of the patients above has a) an overactive and b) an underactive thyroid. Indicate the
likely results of thyroid function testing in each case.
2. Outline the key clinical features that suggest the diagnosis of underactive and overactive thyroid
disease in each case.
3. What anatomical structures are likely to be affected by an enlarged thyroid gland?
4. Adrenal Disorders
Case History
Case 1
A 30 year old man suffers from adrenal failure.
Questions:
1. What symptoms will he complain of? Briefly explain why he has such a good tan, despite not
going on a sunny holiday.
Case 2
A 55-year old female complains that she has been increasing in weight over the past five years. She also
has a five year history of high blood pressure.
Questions:
1. What are the most likely hormonal causes of this high blood pressure?
2. A year ago, she fell over and fractured her hip. A bone density scan revealed that she had
osteoporosis. What is osteoporosis?
3. Three months ago, she developed polyuria and polydipsia. She saw her general practitioner who
noted that she had glycosuria on dipstick testing. What important tests should be performed?
4. Over the last few weeks, she has had progressive weakness, affecting her thighs, with difficulty
climbing stairs. What is this condition called?
5. On direct questioning she notes that the shape of her face has changed. She also mentions that
she bruises easily, and that a wound on her shin that she had six months ago has not healed.
What clinical signs would you expect to find on examination?
6. On the basis of your overall interpretation, what is the likely diagnosis?