Context: Steve, a 14 year old white male, is brought to the doctor’s office by h

Question

Context:

Steve, a 14 year old white male, is brought to the doctor’s office by his mother. A former little league baseball All-Star at 10, she said he tried out for the High School Team. But his coordination was not as good, and he seemed to get tired very quickly, complaining of joint and leg muscle aches. He has been growing very fast over the last year or so, and he was wearing size 12 shoe, but without putting on muscle weight like his brother did at that age. Furthermore, his knee joints have been swelling and he has a perpetual sore on his right calf that won’t heal. He has also been complaining that he doesn’t feel good.

These are patient responses and pertinent information – DO NOT ADD YOUR OWN)

Start with general constitution:

Tell me more about how you are feeling. I have been feeling really tired and rundown. It has been hard to concentrate on my homework or have the energy to do anything. I feel like, numb, about stuff.

How long have your knees been hurting? ~2-3 months on and off

What have you been doing for the pain and swelling? Mom gives me ibuprofen

ASSESSMENT:

VS: BP 130/82, PULSE 76, RR 16, T 98.4F, WEIGHT 145 lb, HEIGHT 5’11”

General: 14 y.o. tall, thin, Caucasian male, alert and oriented x3 (A&O x3), low level distress.

HEENT (head, eyes, ears, nose, throat): Normocephalic without evidence of trauma, PEERL (Pupils equal and reactive to light), mucous membranes pink and moist.

Neck supple w/out lymphadenopathy (swollen lymph nodes), thyromegaly (goiter or enlarged thyroid) or carotid bruits (noisy carotid pulse).

LUNGS: Clear to auscultation bilaterally throughout (CTA)

Heart murmur identified.

The 3 possible diagnosis related with above clinical findings are below:

Gigantism: which is a disorder due to excessive growth hormones. These children have enlarged hands and feet. Gain height faster, fatigue and muscle weakness, pain and limited joint mobility.

Thyroid disorder: Especially hypothyroidism in which there is decreased production of thyroid hormone by the thyroid gland. This disease may precipitate fatigue, muscle weakness, growth disturbances, painful joints

Diabetes: Lack of insulin effect the arrangement of growth hormone which can be evidenced by non-healing sore of right calf. The insulin affects the GHR sensitivity and the level of insulin like growth factor -1 thus influences the level of growth hormone.

Question 1 Plan: Follow up tests/studies – 15 points

This section is important because you will chose THE MOST LIKELY DIAGNOSIS FROM THE 3 ABOVE IN YOUR OPINION and follow up with that one diagnosis only. These tests should be specific in nature and allow you to determine whether or not the patient has that particular problem/disease. You should include information demonstrating you understand how the test is conducted, any principles behind it and predict what it will show. These tests can either be specific for the condition (if commercially available) or exclusive of other conditions (ruling the other stuff out).

Question 2 Pathophysiology: 25 points. Even if your diagnosis is not the actual one, as long as you have a good explanation for the ONE you chose, you WILL GET FULL CREDIT. There are 4 criteria you should always address in this answer. 1) How does the disease/condition make the person feel sick, 2) what is a treatment for it, 3) how does the treatment work to counter the disease/condition, 4) how does it affect the patient’s symptoms. Remember this section alone is worth 25% of this part of the exam. So be as thorough as possible.

Question 3– Follow-up – 5 points

In this section, you describe different things you would look for and ask about in a follow up appointment with the patient. You will be responsible for determining how the patient is responding.

Explanation / Answer

Answer for Q: 1:

From my understating of the above case I would recommend a blood test to measure levels of growth hormones and insulin-like growth factor 1 (IGF-1), which is a hormone produced by the liver.

I would also recommend an oral glucose tolerance test.

During an oral glucose tolerance test, child will drink a special beverage containing glucose, a type of sugar. Blood samples will be taken before and after the child drinks the beverage.

In a normal body, growth hormone levels will drop after eating or drinking glucose. If child’s levels remain the same, it means their body is producing too much growth hormone.

When the blood tests indicate gigantism, child will need an MRI scan of the pituitary gland which is used to find the tumor and see its size and position.

Answer for Q: 2:

1) How does the disease/condition make the person feel sick?

Gigantism is caused by the pituitary gland overproducing growth hormone (GH) over time. The pituitary, a small gland situated at the base of your brain behind the bridge of your nose, produces a number of hormones. GH plays an important role in managing your physical growth.

When GH is secreted into your bloodstream, it triggers your liver to produce a hormone called insulin-like growth factor-I (IGF-I). In turn, IGF-I stimulates the growth of bones and other tissues. If your pituitary gland makes too much GH, excessive amounts of IGF-I can result. Too much IGF-I can cause abnormal growth of your soft tissues and skeleton.

Acromegaly or gigantism may produce the following signs and symptoms,

2) What is a treatment for it?

Treatments for gigantism aim to stop or slow child’s production of growth hormones.

Some of the suggested treatments are:

1.Surgery

Removing the tumor is the preferred treatment for gigantism if it’s the underlying cause.

2. Medication

In some cases, surgery may not be an option. For example, if there’s a high risk of injury to a critical blood vessel or nerve.

3. Gamma knife radiosurgery

Gamma knife radiosurgery is an option if a traditional surgery isn’t possible.

3) How does the treatment work to counter the disease/condition?

Surgery

The surgeon will reach the tumor by making an incision in child’s nose. Microscopes or small cameras may be used to help the surgeon see the tumor in the gland.

Medication

Medication is recommend  if surgery is not an option. This treatment is meant to either shrink the tumor or stop the production of excess growth hormone.

The drugs octreotide or lanreotide to prevent the growth hormone’s release. These drugs mimic another hormone that stops growth hormone production. They’re usually given as an injection about once a month.

Bromocriptine and cabergoline are drugs that can be used to lower growth hormone levels. These are typically given in pill form. They may be used with octreotide. Octreotide is a synthetic hormone that, when injected, can also lower the levels of growth hormones and IGF-1.

In situations where these drugs are not helpful, daily shots of pegvisomant might be used as well. Pegvisomant is a drug that blocks the effects of growth hormones. This lowers the levels of IGF-1 in your child’s body.

Gamma knife radiosurgery

The “gamma knife” is a collection of highly focused radiation beams. These beams don’t harm the surrounding tissue, but they’re able to deliver a powerful dose of radiation at the point where they combine and hit the tumor. This dose is enough to destroy the tumor.

Gamma knife treatment takes months to years to be fully effective and to return the levels of growth hormone to normal. It’s performed on an outpatient basis under general anesthetic.

However, since the radiation in this type of surgery has been linked to obesity, learning disabilities, and emotional issues in children, it’s usually used only when other treatment options don’t work.

4) How does it affect the patient’s symptoms?

Surgery

In most cases, child should be able to return home from the hospital the day after the surgery.

Question 3– Follow-up

During the follow up of Surgery I would recommend a MRI scan and check the general body height and weight ratio and BP and RR and check for any more symptoms Steve would come across and suggest the relevant medication.

Hence I would conclude that Steve was suffering from Gigantism as per my understanding.   

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