A 36 year old lady, seeing her Family Doctor. Serum results were
Free T4: 9.3 pmol/L (10 - 26)
Free T3: 3.4 pmol/L (3.7 - 6.9)
TSH: 1.8 mU/L (0.25 - 5.5)
Clinical information was 'Previous borderline free T4 and normal TSH.
Significance?
Results from two months previously were
Free T4: 9.8 pmol/L
TSH: 1.2 mU/L
FSH: 5.8 U/L (follicular phase, 2 - 11)
LH: 4.8 U/L (follicular phase 1 - 10)
Testosterone: 0.2 nmol/L (0.3 - 2.9)
Oestradiol: 37 pmol/L (follicular phase 75 - 260)
Clinical information then was 'depressed, decreased libido', and a repeat
in 6 weeks had been suggested.
This Case attracted 34 participants and a major concensus view (only a
minority of participants sounding a cautionary note).
9 participants would discuss this with the Family Doctor on Monday morning;
[0.8]
3 would ask the Family Doctor to 'phone the Department. [0.3*]
7 would query menstrual history, [1.0]
5 would query drug history, [0.8]
3 would query visual field defects [1.3]
1 adding (if abnormal, patient should be referred urgently) [1.6]
3 would query concurrent illness [0.5]
1 would query clinical signs of hypothyroidism [0.3]
1 would query nutritional status. [0.3]
1 would query galactorrhoea. [1.0]
19 participants queried (hypothalamic-) pituitary disease; [1.8]
10 queried a drug effect; [0.3]
2 thought that this was probably not pituitary disease. [-0.5]
14 would suggest referral for endocrine assessment; [2.0]
1 would suggest urgent referral for endocrine assessment; [0.8]
5 would suggest radiology referral for pituitary imaging. [1.0]
15 would measure/ suggest measuring prolactin [1.8]
7 would measure cortisol on the current sample; [0.7]
3 each would suggest measuring
a 9am cortisol [1.0]
urea and electrolytes [0.5*]
a repeat FSH, LH, oestradiol. [0.8]
(1 adding 'at a different stage of the cycle') [1.0]
2 would suggest a short Synacthen test [1.3]
1 each would measure
SHBG [0.5]
HCG [-0.3]
HGH [0.5]
lipids [0.0]
glucose [0.5]
Thyroid function tests by a different method. [1.0]
I was concerned about this combination of results together with the initial
clinical information and 'phoned the Family Doctor on Monday morning. The
only prescribed drug was a low dosage of amitriptyline, started after the
first visit. I explained that I was concerned about the possibility of
pituitary disease, and suggested referral to our Consultant
Endocrinologist. I also suggested that it would be useful to send a 9am
sample for cortisol and prolactin. However, this has not yet arrived.
As a guide to scoring, this comment/action would score
0.8 for the phone call (but -0.4 after the mean telephone score in previous
cases has been subtracted)
0.8 for asking about drug history
1.8 for querying pituitary disease
2.0 for suggesting endocrine referral
1.8 for suggesting prolactin measurement
1.0 for suggesting a 9 am cortisol
My total comment score {which is predominantly a measure of thoroughness}
is therefore 7.0;
My mean score per component [excluding the 'phone call] - a measure of
efficiency, is therefore 1.5 (7.4 divided by 5 components). I am sure that
this explanation will make the scoring as clear as mud!
Best wishes
Gordon Challand and Li Ping
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