به نام ان که تن را نور جان داد خرد را سوی دانایی عنان داد

به نام ان که تن را نور جان دادخرد را سوی دانایی عنان داد

Endocrine Grand round • By DR RAHMANI and DR NOORBAKHSH

Chief complaint and HPI • CC : Weight gain and lack of height gain • HPI : our patient is a 14-year-old boy who has been referred to endocrine clinic following weight gain(10 kg) specially in central part of his body and lake of height gain(154 cm) from previous year and cushingoid feature

HPI • He had gradually progressive muscle weakness • He has weight gain in previous year • 96.6(57 kg) • 97.6(67 kg) • 97.10(62 kg) • Height:154 cm from previous year

Father height : 178 cm • Mother height: 156 cm • Sister height(22y/o):156 cm • Sister height (11y/o): 145 cm • Mid parental height :173+/-8 • SDS =_1.7 (chronological age=14.5 y) • SDS= _3.7 (bone age=16.5 y)

Family ,drug , social history • Past medical hx : was clear • Family hx : no history of diabetes or HTN ,thyroid, renal stones or other problems • Drug hx : no drug use

Habitual hx : no history of smoking or alcohol consumption • Patient had regulary do wrestling up to 1.5 years ago but he had to stop because of the onset of muscle weakness • Social hx : ejucated

Review of systems • Constitutional state : weakness, fatigue , weight gain in previous year • NO constipation ,anorexisa ,nausea ,vomiting , abdominal pain, myalgia, depression, paresthesia , chest pain , dyspnea ,hematuria , memory loss

Review of systems • Gasterointestinal:Noheartburn,constipation,diarrhea,abdominalpain,difficultswallowing,nausea,vomiting,blood in stool,unexplained changes in bowel habites,incontinence • Psychiatric : being nervous • No insomnia,irriatability, anxeity,recurrent bad thoughts,moodswing,hallucination,compulsion • Puberty : P5 G5

Review of systems • Genitourinary : No dysuria, frequency, urgency, gross hematuria • Neurological : no problem with walking ,muscle weakness • Negative ( frequent headaches , double vision and ptosis, dizziness , tremor, loss of consciousness

Rewiew of systems • Hematologic and lymphatic : easy brusing • No : anemina ,easy bleeding ,unexplained swollen area • Allergy :No • No hey fever, frequent infection , seasonal allergy • Skin : striae on medial site of thigh and abdomen an posterior of calf

Physical Examination • General appearances:14 y/o boy awake and alert who looks the same age • Wt=62 kg Ht=154cm BMI=26.14 • Waist size=91cm • Vital:BP:120/80 PR:75 RR:14 T:37

Physical examination • Head and neck: moon face , buffalo hump • No telangectasia • Thyroid was normal size without nodule • Chest : normal lung and heart sound

Physical examination • Abdomen :red purple wide (1.5 cm) striae • Extremities: • Upper & lower : normal ROM and pulses no fasciculation or atropy • Normal muscle tone • Force of proximal & distl muscels:5/5 • (upper & lower extremetis:5/5)

Neurologic exams • Mental status : normal • Cranial nerve : normal ,fundoscpic exam normal • Sensory exam : normal (position , vibration, monofilament test , cold and warm sensation ) • Reflexses : in upper and lower was equally and normal

physical exam Cerebellar : heel to shin and finger to nose were normal Gait : normal

97.8.10

Over night 1mg dexamethasone test : cortisol:14.8 micg/dl (6.2-19.4) • low dose dexamethasone test: cortisol:4.8 micg/dl (5-23) • ACTH 19.8 pg/ml(7.2_63)

24h urine

Abdoman & pelvic CT with contrast • طحال فرعی به اندازه ۱۹میلیمتر در ناف طحال رویت شد. • افزایش ضخامت body limb مدیالادرنال چپ همراه با تصویر ندول ۱۰ میلیمتری هیپودنس در بادی رویت شد.

Whole body scan by octreotide • Small collection of tracer splenic hilum can be in favor of accessory spleen • With respect to somewhat higher uptake of pituitary gland , microadenomatous involvement cannot be excluded

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