Instructions 1. Visit the New England Journal of Medicine Interactive Cases Home Page.(Links to an external site.) You will be choosing one of the cases below (see below, Option 1 and Option 2). The...

Case 1

1. Visit theNEJM Interactive Medical Cases page(Links to an external site.)

2. Search for the case "A Man With Bizarre Behavior."

3. Launch the activity. You might check the browser and technology recommendations before beginning to ensure usability.

4. Navigate through the activity by reading each page, then clicking "next" on the lower right hand side of the page.

5. When questions appear, you MUST answer them in order to move on. When you submit your answers, feedback with explanations will appear on the right side of the page. You don't need to get the questions correct.

6. You will be asked to share your experience and some information about this activity in discussions. (note that questions and learning modules 1 (drug effects on behavior), 5 (treatments) that are fun but not relevant to our class- feel free to participate and learn about them, but they certainly are not anything you need to know)

With all of these questions, the goal is to share information with your peers, and get a deeper understanding yourself. Don't stress over getting everything exactly right. A lot of this goes beyond the requirements of our class. The most important questions below are #7, #8, #11, and #18-20.

Here is what to focus on and answer.Questions to answer in discussions are in bold.

1. Read the introductory page describing the patient's presentation, then click through the activity, spending as much or as little time with the information as you'd like, until you get to page 6.


2. When you get to "Physical Exam," (pg. 6) note the patient's vital signs. Here are normal values: temperature 37 C, HR 60-80 beats/min, RR 12-20 breaths/min, bp 95%.How do the patient's vital signs compare?
   


3. Also on physical exam, the doctor notes that the patient isdiaphoretic. What does that mean?(just do a quick google search)


4. Based on the patient's behavior and vital signs,do any possible endocrine diagnoses come to mind? Share. Later in the case, we learn that the patient's blood glucose is elevated. Does that affect your suspicions?
   


5. Question 2 (pg. 7): submit your answer. An explanation will pop up.In your own words, BRIEFLY explain which 2 tests were recommended, and why.
   


6. Lab results (pg. 8):which hormone levels were abnormal?(you don't need to list all abnormal test results, just the hormones)


7. Both thyroxine and triiodothyronine were measured.What's the difference between thyroxine and triiodothyronine
   ?
   


8. Free and total thyroxine were measured. Most thyroxine is bound to proteins in the plasma.Why? (hint: it has to do with solubility)
   


9. Attempt question 3 (pg. 9) (which type of thyroid problem is most likely) and briefly read through the explanation. Don't spend too much time on it.


10. Now that we know the patient's diagnosis,explain his abnormal vital signs.
    


11. Play with learning module 3. Answer:
    
    
    1. 
       Why is thyroxine low, but thyrotropin (TSH) high, in primary hypothyroidism?
       
    
    
    2. 
       Why is thyroxine high, but thyrotropin (TSH) low, in primary hyperthyroidism?
       
    
    
    3. 
       Which organ is malfunctioning in secondary hypo- and hyper-thyroidism?
       
    
    
    
    


12. 
    Optional:play learning module 4 (Causes of hyperthyroidism)-if you played with it, what is something you learned?
    


13. Question 4 (pg 12): Submit your answers. Read through the explanation that pops up on the right side of the page.Briefly (a few sentences), in your own words, describe thyroid storm.
    


14. Question 5 and learning module 5 are beyond the scope of our class (treatment options), but feel free to explore them!


15. Lab results (pg. 16): notice the patient's thyroxine levels after 10 days of pharmaceutical treatment.


16. Question 6 (pg. 17): Submit your answer. Read through the explanation that pops up on the right side of the page.Briefly explain which ion can become dysregulated after thyroidectomy, and why.
    


17. 
    Why do you think the doctors decided that thyroidectomy was the best course of action? How did the patient's thyroid gland compare to a normal thyroid gland?
    


18. 
    How were the pt's calcium and PTH levels affected soon after the surgery? Did they resurge? Does that mean his parathyroid glands are probably still present in his body?
    


19. 
    What are the three primary effects of PTH?
    


20. 
    Where in the body is calcitriol activated, and what is its primary effect related to calcium?
    


21. 
    What was your overall impression and experience with this activity?
    

Case 2

1. Visit theNEJM Interactive Medical Cases page(Links to an external site.)

2. Search for the case "Take it With a Grain of Salt."

3. Launch the activity. You might check the browser and technology recommendations before beginning to ensure usability.

4. Navigate through the activity by reading each page, then clicking "next" on the lower right hand side of the page.

5. When questions appear, you MUST answer them in order to move on. When you submit your answers, feedback with explanations will appear on the right side of the page. You don't need to get the questions correct.

With all of these questions, the goal is to share information with your peers, and get a deeper understanding yourself. Don't stress over getting everything exactly right. A lot of this goes beyond the requirements of our class.

Instructions and questions for the Activity:

1. Read and click through the presenting symptoms and Physical Exam. Note- the physical exam is mostly normal, but the O2 saturation is low and the patient's diastolic blood pressure is kind of low- could be normal for her, but something to keep in the back pocket.

2. Blood lab results:Answer:
Which results were abnormal?

3.Optional:Clickhere(Links to an external site.)for a very short, straightforward explanation of serum osmolality, if you are interested.

4. Question 1: You can probably figure this one out, or come close, based on what you know about hormones, plus some extra info I'll include here. If you are time-constrained, don't feel obligated, but if you'd like to try to figure this out, here is the information I think will help you:

• It is not heart failure or cirrhosis


• SIADH is an over-secretion of ADH


• central diabetes insipidus is under-secretion of ADH


• nephrogenic diabetes insipidus means excessive urination caused by kidney dysfunction


• primary polydipsia is excessive fluid intake caused by psychiatric disorders


• cortisol deficiency is… what it sound like :) But- here is an extra piece of information about cortisol that could be relevant: while not well understood, cortisol seems to inhibit ADH secretion.

5.Answer: what are the possible diagnoses? Why/how could each of them cause hyponatremia (low Na+)?

6. Learning module: "Causes of Hyponatremia:" Read it over briefly. Notice adrenal insufficiency is listed in two places. Adrenal insufficiency is specific to the adrenal cortex.Answer: what hormones are secreted by the adrenal cortex? Why would deficiency of these hormones cause hyponatremia?

7. "What Would You Do?" This page is beyond the scope of our class, but for those of you planning to become clinicians, you may want to remember this as a resource for the future!

8. Further Lab findings:Answer: Which results were abnormal? This combination of results points to dysfunction of one specific organ. What organ is it?

9.Answer: Given the low T4 and high PRL, what are a couple of other signs/symptoms might this patient be experiencing?

10. Question 2: Again, you may be able to predict the answers to this! You are not required to answer it, but if you'd like to try, here is some information you will need:

• “Primary” thyroid/cortisol problem means the thyroid gland or adrenal gland is dysfunctional.


• “Secondary” means the organ that secretes their stimulating hormones is dysfunctional.

11. Learning Module: click and briefly read through the learning module.

12. The remainder of the case clarifies diagnosis, discusses treatment (including surgery) and follow-up. This is beyond the scope of the class, but you may be interested in it. Feel free to spend as much or as little time with it as you'd like.

13.Answer:

• 
  Before the patient's treatment, do you expect that her CRH, TRH, and GnRH were elevated or depressed? Explain.
  


• 
  Based on the explanations of the patient's specific diagnosis in the Learning Module, why did she experience headaches and vomiting?
  

14. Answer: what was your overall experience with this activity?