General medicine | cases
HNH-27806
Internal medicine
Case 1
A 19-year old woman Mrs Thompson comes to the GP with complaints of restlessness, palpitations and amenorrhoea. The
bulging eyes are noticeable, but nothing else. He referred her to the hospital. At the department of internal medicine, they
see also a diffuse enlarged thyroid and they can hear a continuous murmur.
Diagnostic results
- High T4
- Low TSH
- Pregnancy test: negative
Hyperthyroidism: enlarged thyroid, bulging eyes (proptosis), restlessness, palpitations, ammenorrhoea, lab results
Not plausible:
- Hypothyroidism: enlarged thyroid could be a symptom, but it’s rare. Lab results do not show hypothyroidism
- Pelvic inflammatory disease: she is at risk and irregular menstrual bleeding is a symptom, but enlarged thyroid and
lab results would not be explained.
- Anaemia: tiredness and palpitations match, but enlarged thyroid and lab results cannot be explained
- Anorexia nervosa: tiredness and amenorrhoea are explained, but enlarged thyroid and palpitations are not
Case 2
Mrs. Tense, a 36-year-old woman, consults her General Practitioner (GP) for the second time this month. She is once again
concerned about her fatigue and gradual weight loss during the last three months (6 kg). She tells her GP that she and
her husband lately have a lot of arguments about little things and she sometimes feels irritated by him. It also worries her
husband because they used to be quite a harmonious couple.
On careful questioning she reports that she often needs to go to the toilet during the day. She also sleeps very badly,
because lately she frequently needs to micturate at night (sometimes even three times). During the last weeks Mrs. Tense
drinks at least 20 glasses of water per day instead of the usual four. The GP notices a slight tremor of her hands. Her
temperature is normal and she doesn’t complain about painful voiding. Mrs. Tense uses oral contraceptives and her
bleeding pattern is regular.
The GP checks his medical record and sees that she has an unremarkable medical history. He knows that she has lost her
youngest daughter in a car accident ten months ago. In her family diabetes has a high prevalence; her mother died as
the result of renal failure 9 years ago.
Physical examination shows normal findings except for a pulse rate of approximately 100 beats per minute and her weight
of 75 kg (1.63 m). Her BMI is 28 kg/m².
To obtain more information the GP decides to perform the following diagnostic examinations and tests:
- Urine analysis: microscopy, urine culture tests, glucose, sodium (Na+), potassium (K+), protein, ketones, and albumin.
- Blood tests: glucose, Hb (haemoglobin), thyroid hormones (T3 and T4), TSH (thyroid stimulating hormone), sodium
(Na+), potassium (K+), LH (luteinizing hormone), FSH (follicle stimulating hormone), creatin, albumin, and
estradiol/total oestrogen.
Diagnostic results
- High glucose
- Increased thyroid hormones
- Low TSH
Diabetes mellitus type 1 or 2: drinking much water, frequently micturating, family history of diabetes, high blood glucose
Later age and no symptoms of ketoacidosis; probably diabetes type 2.
Hyperthyroidism: high pulse rate, irritability, agitation, low TSH and high thyroid hormones
Not/less plausible
- Depression: lost her daughter, irratibility. Although diagnostic results not explained
- Cystitis: no painful micturition, urine analysis is normal
- Hypothyroidism: irratibility, fast pulse do not match
, - Premature menopause: complaints do not match, menstruation is normal
Obesity
Case 1
A few weeks ago, mrs Sunflower underwent a Roux-en-Y gastric bypass (RYGB). Recently, she visited the surgeon because
of abdominal pain, nausea and diarrhoea 3-4 times per day. Besides, she complains of cold sweats and dizziness and
she feels exhausted. Her complaints occur after every meal, but especially after eating carbohydrates. Mrs Sunflower
also suffers from DM type 2, which is treated with insulin therapy. The insulin dose has been adjusted after surgery.
Diagnostic results
- Normal IgA
- Endomysial antibodies negative
- Normal CRP
Dumping syndrome: abdominal pain, nausea, diarrhoea, dizziness, especially after eating carbohydrates
Further investigation could include a gastric emptying scan to see if gastric emptying is indeed increased
Not/less plausible
- Coeliac disease: no IgA deficiency and absence of endomysial antibodies
- Peptic ulcer disease: complaints start 30 minutes after meal, with peptic ulcer disease this would be between 90
minutes-3 hours after a meal. Endoscope shows normal RYGB with no inflammation
- Cholecystitis: no signs of infection (normal CRP) and no fever
Case 2
Mr. Taylor has lost 30 kg after his RYGB surgery two years ago. He currently has a BMI of 27 and is very happy with this
result. However, the last couple of weeks he felt tired and weak. He has some troubles with his daily activities as he
already feels exhausted after vacuum cleening or making the bed. He also noticed a tingling sensation in his fingertips.
His wife mentions that he sometimes acts confused or speaks a bit slurred. Maybe because he started drinking alcoholic
beverages again? Before his surgery, Mr. Taylor had diabetes type 2, for which he used oral medication. Since his HbA1C
was very low last year, he could stop using Metformin. He also uses multivitamin supplements on a daily basis.
Diagnostic results
- Normal ALAT and ASAT
- Normal sodium
- Normal potassium
- Normal folic acid
- Low vitamin B12
- Normal vitamin B1
- Normal vitamin B6
- Normal HbA1c
Vitamin B12 deficiency: causes fatigue and weakness, tingling in fingers and change in speech. Using metformin might
have aggravated the deficiency, because it inhibits B12 absorption
Not/less plausible
- Zinc deficiency: would explain tiredness and weakness, other complaints do not match. Blood test needed
- Diabetic neuropathy: tingling in fingers explained, but bypass surgery normally leads to remission of diabetes, this is
also shown in is low HbA1c and stopping with metformin
- Vitamin B6 intoxication: could lead to neuropathy, however vitamin B6 levels are normal
Case 3
Mrs Smith, 24 years old, visits the GP because of significant weight gain. Her weight is 153 kg and her height is 1.77 m.
(BMI=48.8) She has always been overweight, but she gained an additional 20 kg since she moved in with her boyfriend
last year. Her family members have a normal weight. They always advice Mrs Smith to go to a dietician, but Mrs Smith
thinks that she is eating healthy because she eats 200 grams of vegetables (almost) every day. She does not have episodes
of binge eating. She started antidepressants a few months ago for her mild depression. Mrs Smith noticed that her
menstruation is irregular, but you do not see any facial hairs and no red cheeks. You are surprised that she is
wearing a t-shirt while it is 5ºC outside.
Obesity due to lifestyle: she has always been overweight, she thinks she eats healthy, but she never visited a dietician.
Irregular menstruation is also more common in obese women.
HNH-27806
Internal medicine
Case 1
A 19-year old woman Mrs Thompson comes to the GP with complaints of restlessness, palpitations and amenorrhoea. The
bulging eyes are noticeable, but nothing else. He referred her to the hospital. At the department of internal medicine, they
see also a diffuse enlarged thyroid and they can hear a continuous murmur.
Diagnostic results
- High T4
- Low TSH
- Pregnancy test: negative
Hyperthyroidism: enlarged thyroid, bulging eyes (proptosis), restlessness, palpitations, ammenorrhoea, lab results
Not plausible:
- Hypothyroidism: enlarged thyroid could be a symptom, but it’s rare. Lab results do not show hypothyroidism
- Pelvic inflammatory disease: she is at risk and irregular menstrual bleeding is a symptom, but enlarged thyroid and
lab results would not be explained.
- Anaemia: tiredness and palpitations match, but enlarged thyroid and lab results cannot be explained
- Anorexia nervosa: tiredness and amenorrhoea are explained, but enlarged thyroid and palpitations are not
Case 2
Mrs. Tense, a 36-year-old woman, consults her General Practitioner (GP) for the second time this month. She is once again
concerned about her fatigue and gradual weight loss during the last three months (6 kg). She tells her GP that she and
her husband lately have a lot of arguments about little things and she sometimes feels irritated by him. It also worries her
husband because they used to be quite a harmonious couple.
On careful questioning she reports that she often needs to go to the toilet during the day. She also sleeps very badly,
because lately she frequently needs to micturate at night (sometimes even three times). During the last weeks Mrs. Tense
drinks at least 20 glasses of water per day instead of the usual four. The GP notices a slight tremor of her hands. Her
temperature is normal and she doesn’t complain about painful voiding. Mrs. Tense uses oral contraceptives and her
bleeding pattern is regular.
The GP checks his medical record and sees that she has an unremarkable medical history. He knows that she has lost her
youngest daughter in a car accident ten months ago. In her family diabetes has a high prevalence; her mother died as
the result of renal failure 9 years ago.
Physical examination shows normal findings except for a pulse rate of approximately 100 beats per minute and her weight
of 75 kg (1.63 m). Her BMI is 28 kg/m².
To obtain more information the GP decides to perform the following diagnostic examinations and tests:
- Urine analysis: microscopy, urine culture tests, glucose, sodium (Na+), potassium (K+), protein, ketones, and albumin.
- Blood tests: glucose, Hb (haemoglobin), thyroid hormones (T3 and T4), TSH (thyroid stimulating hormone), sodium
(Na+), potassium (K+), LH (luteinizing hormone), FSH (follicle stimulating hormone), creatin, albumin, and
estradiol/total oestrogen.
Diagnostic results
- High glucose
- Increased thyroid hormones
- Low TSH
Diabetes mellitus type 1 or 2: drinking much water, frequently micturating, family history of diabetes, high blood glucose
Later age and no symptoms of ketoacidosis; probably diabetes type 2.
Hyperthyroidism: high pulse rate, irritability, agitation, low TSH and high thyroid hormones
Not/less plausible
- Depression: lost her daughter, irratibility. Although diagnostic results not explained
- Cystitis: no painful micturition, urine analysis is normal
- Hypothyroidism: irratibility, fast pulse do not match
, - Premature menopause: complaints do not match, menstruation is normal
Obesity
Case 1
A few weeks ago, mrs Sunflower underwent a Roux-en-Y gastric bypass (RYGB). Recently, she visited the surgeon because
of abdominal pain, nausea and diarrhoea 3-4 times per day. Besides, she complains of cold sweats and dizziness and
she feels exhausted. Her complaints occur after every meal, but especially after eating carbohydrates. Mrs Sunflower
also suffers from DM type 2, which is treated with insulin therapy. The insulin dose has been adjusted after surgery.
Diagnostic results
- Normal IgA
- Endomysial antibodies negative
- Normal CRP
Dumping syndrome: abdominal pain, nausea, diarrhoea, dizziness, especially after eating carbohydrates
Further investigation could include a gastric emptying scan to see if gastric emptying is indeed increased
Not/less plausible
- Coeliac disease: no IgA deficiency and absence of endomysial antibodies
- Peptic ulcer disease: complaints start 30 minutes after meal, with peptic ulcer disease this would be between 90
minutes-3 hours after a meal. Endoscope shows normal RYGB with no inflammation
- Cholecystitis: no signs of infection (normal CRP) and no fever
Case 2
Mr. Taylor has lost 30 kg after his RYGB surgery two years ago. He currently has a BMI of 27 and is very happy with this
result. However, the last couple of weeks he felt tired and weak. He has some troubles with his daily activities as he
already feels exhausted after vacuum cleening or making the bed. He also noticed a tingling sensation in his fingertips.
His wife mentions that he sometimes acts confused or speaks a bit slurred. Maybe because he started drinking alcoholic
beverages again? Before his surgery, Mr. Taylor had diabetes type 2, for which he used oral medication. Since his HbA1C
was very low last year, he could stop using Metformin. He also uses multivitamin supplements on a daily basis.
Diagnostic results
- Normal ALAT and ASAT
- Normal sodium
- Normal potassium
- Normal folic acid
- Low vitamin B12
- Normal vitamin B1
- Normal vitamin B6
- Normal HbA1c
Vitamin B12 deficiency: causes fatigue and weakness, tingling in fingers and change in speech. Using metformin might
have aggravated the deficiency, because it inhibits B12 absorption
Not/less plausible
- Zinc deficiency: would explain tiredness and weakness, other complaints do not match. Blood test needed
- Diabetic neuropathy: tingling in fingers explained, but bypass surgery normally leads to remission of diabetes, this is
also shown in is low HbA1c and stopping with metformin
- Vitamin B6 intoxication: could lead to neuropathy, however vitamin B6 levels are normal
Case 3
Mrs Smith, 24 years old, visits the GP because of significant weight gain. Her weight is 153 kg and her height is 1.77 m.
(BMI=48.8) She has always been overweight, but she gained an additional 20 kg since she moved in with her boyfriend
last year. Her family members have a normal weight. They always advice Mrs Smith to go to a dietician, but Mrs Smith
thinks that she is eating healthy because she eats 200 grams of vegetables (almost) every day. She does not have episodes
of binge eating. She started antidepressants a few months ago for her mild depression. Mrs Smith noticed that her
menstruation is irregular, but you do not see any facial hairs and no red cheeks. You are surprised that she is
wearing a t-shirt while it is 5ºC outside.
Obesity due to lifestyle: she has always been overweight, she thinks she eats healthy, but she never visited a dietician.
Irregular menstruation is also more common in obese women.
