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MedicalCareer版 - 请教一道CD题
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话题: insulin话题: insulinoma话题: pituitary话题: level
进入MedicalCareer版参与讨论
1 (共1页)
z******8
发帖数: 844
1
A previously healthy 32-year-old woman who works as a nurse comes to the
emergency department because of a 3-week history of episodes of dizziness,
nausea, and profuse sweating that resolve with eating. She does not smoke.
She drinks four glasses of wine weekly. Vital signs are within normal limits
. Physical examination shows no abnormalities. While in the emergency
department, she becomes dizzy and diaphoretic; and her serum glucose
concentration is 45 mg/dL. Laboratory studies obtained during the episode
show:
请问诊断是什么?
z**********4
发帖数: 467
2
Look like a insulinoma.
z******8
发帖数: 844
3
感谢感谢,How to explain the normal level of insulin?
z**********4
发帖数: 467
4
En...it is upper limit... Look at C peptide.
z******8
发帖数: 844
5

Thanks, the level of insulin is varying or constant?

【在 z**********4 的大作中提到】
: En...it is upper limit... Look at C peptide.
J*********4
发帖数: 1274
6
The level of insulin should be inversely correlates with blood glucose level
. The fact that at the very low level of Glucose (35mg/ml), the insulin
level of nearly upper limit is absolutely abnormal.
Since the patient is a nurse, it also need to exclude the possibility of
self-administration of insulin.
h**s
发帖数: 1757
7
Should be E.
I do not think this is insulinoma b/c c- peptid and insulin are both normal.
This patient has several hypoglycemia. It can be from Addision's disease.
And for Addision's disease , common from pituitary disease.
J*********4
发帖数: 1274
8
hmis,
First, the cortisol level is normal here, which is inconsistent with Addison
's disease. Moreover, the cardinal signs and symptoms of Addision's disease,
hypotension, hyponatriemia, hyperkalemia and darkened skin are not
reflected in this patient. Last, there seems no pituitary tumor that could
suppress production of aldosterone or cortisol.
Thanks for discussing it.
h**s
发帖数: 1757
9
You r right, however what u discribed is primary Addision's disease. If I
mean primary Addision's, the patient should have high pigmentation which
means low cortisol high ACTH. Obviously not this case. That is why we won't
go to answer A.
Then, u can think may secondary Addision's disease. That is the disease of
pituitary. Then low ACTH , low Cortisol. Patient won't have high
pigmentation due to low ACTH . Right?
Usuarally, in an emergency situation, cortisol ,as a very important hormone,
should rise up. Look at this patient , only at low normal. I felt it is not
normal sign.
This is one reason.
Second reason, low cortisol can severely icrease insulin sensitivity. That
can be the other reason.
What do u think?

Addison
disease,
could

【在 J*********4 的大作中提到】
: hmis,
: First, the cortisol level is normal here, which is inconsistent with Addison
: 's disease. Moreover, the cardinal signs and symptoms of Addision's disease,
: hypotension, hyponatriemia, hyperkalemia and darkened skin are not
: reflected in this patient. Last, there seems no pituitary tumor that could
: suppress production of aldosterone or cortisol.
: Thanks for discussing it.

q**d
发帖数: 109
10
这道题要是有外源胰岛素注射选项就完美了,可惜没有。 pituitary gland can not
explain anything in this question.
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h**s
发帖数: 1757
11
Why? Give a reason? Why not pituitary gland explain it?

【在 q**d 的大作中提到】
: 这道题要是有外源胰岛素注射选项就完美了,可惜没有。 pituitary gland can not
: explain anything in this question.

q**d
发帖数: 109
12
hmis是高手,这次读题不仔细了。智者千虑,偶有一失。
A previously healthy 32-year-old woman nurse , a 3-week history of
episodes of dizziness,
nausea, and profuse sweating that resolve with eating.. Vital signs are
within normal limits
. Physical examination shows no abnormalities. and her serum glucose
concentration is 45 mg/dL.
h**s
发帖数: 1757
13
不是高手,只是我一直在内分泌做见习。所以感兴趣。聊聊呗。当然,医护人员首选考
虑滥用药物。 不过这道题,我反而觉得给护士是迷糊大家的。usmle考的还是基本概念
。交流交流。。。
带我见习的老教授和我讨论了一下这个题。 顺便介绍了一下我们这个论坛

【在 q**d 的大作中提到】
: hmis是高手,这次读题不仔细了。智者千虑,偶有一失。
: A previously healthy 32-year-old woman nurse , a 3-week history of
: episodes of dizziness,
: nausea, and profuse sweating that resolve with eating.. Vital signs are
: within normal limits
: . Physical examination shows no abnormalities. and her serum glucose
: concentration is 45 mg/dL.

q**d
发帖数: 109
14
用最简单的单一疾病做诊断。hmis老师说的很深奥,途径从头到腰。的确,pituitary
gland problem can explain part of this patient's low glucose level, however,
pituitary gland problem will also cause adrenal cortex a series of changes
which never showed up in this patient.
As a physician, it is not correct to use a very complicated and rare disease
to explain only part of the whole picture.
这个题,C-peptide level 低,是唯一不完满的地方,但是用胰岛素瘤能解释的通,脉
冲释放。
hmis其他的解释的很好受教了。
h**s
发帖数: 1757
15
Nice, let me keep this q and send out to another professor. C what does she
think? Then we can learn more...haha I like this discussion. Very nice!
Thanks, enjoy

pituitary
however,
changes
disease

【在 q**d 的大作中提到】
: 用最简单的单一疾病做诊断。hmis老师说的很深奥,途径从头到腰。的确,pituitary
: gland problem can explain part of this patient's low glucose level, however,
: pituitary gland problem will also cause adrenal cortex a series of changes
: which never showed up in this patient.
: As a physician, it is not correct to use a very complicated and rare disease
: to explain only part of the whole picture.
: 这个题,C-peptide level 低,是唯一不完满的地方,但是用胰岛素瘤能解释的通,脉
: 冲释放。
: hmis其他的解释的很好受教了。

J*********4
发帖数: 1274
16
Thank great discussion from both of you. hmis, I agree with you on most of
thing. But the question ask here is " what tumor" is most likely. Can you
think of a pituitary tumor that reduce level of ACTH?
I think what the question here limited a lot of possibilities.. and in
reality, there are more scenario...
z**********4
发帖数: 467
17
Pure assumption:
C-peptide level can only be released by normal "islet cells". Insulinoma
does not contain normal "islet cells" which could not efficiently cleave pro
-insulin peptide to Cpeptide. Waiting for more evidence.
J*********4
发帖数: 1274
18
Zhanghaowei4,
You are right! Insulinoma could have much higher proinsulin rather than
mature insulin, which might explain the borderline level of both insulin and
c-peptide level.
h**s
发帖数: 1757
19
non functional adenoma? I saw several cases in our hospital. It won't
directly reduce the hormone level itself. However , will effect the normal
tissue function

of

【在 J*********4 的大作中提到】
: Thank great discussion from both of you. hmis, I agree with you on most of
: thing. But the question ask here is " what tumor" is most likely. Can you
: think of a pituitary tumor that reduce level of ACTH?
: I think what the question here limited a lot of possibilities.. and in
: reality, there are more scenario...
:

h**s
发帖数: 1757
20
Do u have any paper to support your assumption? I could not find to support
this hypothesis.
If like you said, then it will be very confused Between insulinoma And
exagenous insulin abuse.

pro

【在 z**********4 的大作中提到】
: Pure assumption:
: C-peptide level can only be released by normal "islet cells". Insulinoma
: does not contain normal "islet cells" which could not efficiently cleave pro
: -insulin peptide to Cpeptide. Waiting for more evidence.

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急问这道题急,请教一道step 3的题目,谢谢。
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J*********4
发帖数: 1274
J*********4
发帖数: 1274
22
hmis, thanks for your very informative posts. Have a nice weekend.
b******a
发帖数: 704
23
Failure of endogenous insulin secretion to be suppressed by hypoglycemia is
the hallmark of an insulinoma. Thus, the finding of inappropriately elevated
levels of insulin in the face of hypoglycemia is the key to diagnosis. A
plasma insulin concentration of >3 microU/mL (20.8 pmol/L) when the plasma
glucose concentration is below 55 mg/dL (3.0 mmol/L) indicates an excess of
insulin and is consistent with insulinoma.
Plasma C-peptide distinguishes endogenous from exogenous hyperinsulinemia.
In patients in whom plasma glucose concentrations fell below 45 mg/dL (2.5
mmol/L), there was no much overlap in the values in insulinoma patients and
normal subjects at a plasma C-peptide concentration of 0.2 nmol/L (0.6 ng/mL
). All insulinoma patients had higher values and all normal subjects who
were hypoglycemic had lower values.
For plasma proinsulin, the diagnostic criterion for insulinoma is 5 pmol/L
or greater.
Given that this patient has Whipple’s triad, inappropriately elevated
levels of insulin during hypoglycemic attack, urine sulfonylurea negative,
insulinoma is the most likely diagnosis. Work up including a 72-hour fast
test to provoke hypoglycemia, measuring plasma glucose, insulin, C-peptide,
proinsulin at same time when glucose concentration is below 55 mg/dL.
Need to rule out MEN1 syndrome.
Other DD:
1. Insulin autoimmune hypoglycemia
2. Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) caused by
islet hypertrophy and nesidioblastosis. An unusual feature of this disorder
is that hypoglycemia occurs postprandially, two to four hours after a meal.
Fasting hypoglycemia, characteristic of insulinoma, is rare in this
disorder
3. Nonislet cell tumor-induced hypoglycemia: increased production of
IGFII
4. Persistent hyperinsulinemic hypoglycemia of infancy.
http://emedicine.medscape.com/article/283039-workup#a0719
Patients with chronic adrenal insufficiency usually have symptoms such as
weakness, fatigue, poor appetite, and weight loss, orthostatic hypotension,
reduced libido/ amenorrhea (2nd), hypoglycemic episodes due to an increase
in
insulin sensitivity. In addition, this patient’s cortisol level was still
within normal range.

level

【在 J*********4 的大作中提到】
: The level of insulin should be inversely correlates with blood glucose level
: . The fact that at the very low level of Glucose (35mg/ml), the insulin
: level of nearly upper limit is absolutely abnormal.
: Since the patient is a nurse, it also need to exclude the possibility of
: self-administration of insulin.

J*********4
发帖数: 1274
24
bythesea,
受教了, 谢谢!
s********o
发帖数: 3319
25
大家懂太多了,所以喜欢联想翩翩。象我看一眼题就只能想起一个诊断,就是
insulinoma,然后毫不犹豫地选胰腺,再不会去看它一眼 LOL
z**********4
发帖数: 467
26
I would prefer exogenous insulin abuse. But there are no options like that.
I have no idea why C peptide is so low though. Haha..lab technique errors?

support

【在 h**s 的大作中提到】
: Do u have any paper to support your assumption? I could not find to support
: this hypothesis.
: If like you said, then it will be very confused Between insulinoma And
: exagenous insulin abuse.
:
: pro

s********o
发帖数: 3319
27
LOL when I saw "nurse" I also jumped to find malingering/factitious..

.

【在 z**********4 的大作中提到】
: I would prefer exogenous insulin abuse. But there are no options like that.
: I have no idea why C peptide is so low though. Haha..lab technique errors?
:
: support

s********o
发帖数: 3319
28
low C-peptide makes C not a perfect answer. but pancreas is the MOST LIKELY
to me.
too little information is provided to make a Dx of Addison's disease...and
how can you tell whether it is due to pituitary or adrenal...
D*********t
发帖数: 140
29
I agree with hmis! First, the low limit of C peptide level together with a
high limit insulin level rules out insulinoma. This is because C peptide is
cleaved from proinsulin together with insulin and thus it should be always
parallel to the insulin level. Second, I think the possibility of pituitary
disease is the low level of cortisol. In hypoglycemia condition, cortisol
should be increased as response to stress. But cortisol in this patient is
still in low limit, indicating a failure to response! Pituitary is in a
lower than normal function to release enough ACTH to stimulate cortisol
production. But I have difficulty to find out what exact disease it might be
if hypopituitarism can not be sold.So, ACTH level or cosyntropin test will
be the best way to make it more clear.
h**s
发帖数: 1757
30
Because we have two adrenal glands and one pituitary. That why secondary is
more common than primary addision?

LIKELY

【在 s********o 的大作中提到】
: low C-peptide makes C not a perfect answer. but pancreas is the MOST LIKELY
: to me.
: too little information is provided to make a Dx of Addison's disease...and
: how can you tell whether it is due to pituitary or adrenal...

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b******a
发帖数: 704
31
呵呵,我赞同你和qdmd的意见,毛病犯了抄书而已。
正常值可能只是在正常情况下的正常人群中的一个%区间。考试大都不会考虑测量误差
,但实际中,可能也是有误差的。 所以要重复测一下C-peptide。 如果没有相
对胰岛素过高的情况下,cortisol相对低也可以考虑一下。如果有胰岛素对血糖比值过
高,还是直接选胰腺吧。 后者可能性小。
对此题来说,猜测,外源性insulin是最大的混淆项,所以考题很直接的避开了,不要
说放入混淆选项,问都不敢问。 出题的人也难啊。 同样的题干,加减一下病史,换个
问题问,就是别的诊断和答案了。 难怪总说题很熟悉,护士/PA职业经常打酱油出现。。
。出题的人也懒啊。
所以考试就是考试,来源于生活,简单于生活,参照250(分)蝎子就行了。

【在 J*********4 的大作中提到】
: bythesea,
: 受教了, 谢谢!

d****y
发帖数: 2180
32
Same here. If it's exogenous insulin abuse, then Insulin is high, but c-
peptide would be low.

.

【在 z**********4 的大作中提到】
: I would prefer exogenous insulin abuse. But there are no options like that.
: I have no idea why C peptide is so low though. Haha..lab technique errors?
:
: support

d****y
发帖数: 2180
33
说得很好!

pituitary
however,
changes
disease

【在 q**d 的大作中提到】
: 用最简单的单一疾病做诊断。hmis老师说的很深奥,途径从头到腰。的确,pituitary
: gland problem can explain part of this patient's low glucose level, however,
: pituitary gland problem will also cause adrenal cortex a series of changes
: which never showed up in this patient.
: As a physician, it is not correct to use a very complicated and rare disease
: to explain only part of the whole picture.
: 这个题,C-peptide level 低,是唯一不完满的地方,但是用胰岛素瘤能解释的通,脉
: 冲释放。
: hmis其他的解释的很好受教了。

1 (共1页)
进入MedicalCareer版参与讨论
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相关话题的讨论汇总
话题: insulin话题: insulinoma话题: pituitary话题: level