Dr. Lee sat down at her desk with a weary sigh and rubbed her stiff neck. Someti

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Dr. Lee sat down at her desk with a weary sigh and rubbed her stiff neck. Sometimes she wondered whether it was worth it all. She worked such long hours, and it was so hard to watch helplessly as a patient died. She'd just lost an old dear friend, and there wasn't a thing she could do to stop the relentless spread of her disease. She picked up a fat folder, full of lab tests, notes from office visits, and other documents. Ah yes, this was one of her challenging patients. The guy's hormones were seriously whacked, and trying to keep all of them in balance plus dealing with his high blood pressure was a bit like juggling china plates while riding a unicycle. As if that wasn't enough, he kept coming up with odd things. One morning his right eye stopped working, which led to the diagnosis of an aneurysm in an artery immediately beneath the pituitary. The aneurysm was probably due to radiation damage to the blood vessel walls in the area of the tumor. They had gone in and surgically wrapped it together, but his recovery had taken months. Fourteen months later his right eye began to work again, although he lost most of his peripheral vision. A stroke he had two years later may have been due to radiation or due to high blood pressure, but meant frustratingly long months of physical rehab. And of course, just to make things interesting, he had to have the stroke while he was in a jungle somewhere in Costa Rica. He came home from China testing positive for tuberculosis, from the Marshall Islands with beaver fever, and from Costa Rica with parasitic barflies burrowing under his skin. Botflies! Here in Illinois they only infected sheep. Maybe she was becoming a veterinarian. Well, back to work. Let's see...her patient was 45 years old, 6'6", 310 lbs. At 5'2" she was small to begin with, but he always made her feel tiny. He had two cute adopted daughters. She smiled, thinking of his youngest, Mara, who had given her a rather enthusiastic hug the other day when Dr. Lee had been picking up her daughter Beth from the preschool both girls attended. One of the nice things about small town life was getting to know your patients, and Mara just loved Beth and tried to take care of her at their preschool. Now Eric's wife was complaining he wasn't sleeping enough. Eventually they had figured out that his sleep was getting seriously disrupted by frequent nighttime trips to the bathroom. It's quite normal for a 45-year- old male to make one nighttime visit and dump 350 cc of urine, but Dr. Lee had asked him to record the frequency of his visits and the quantity of urine produced. Her nurse had attached the chart he had just sent. She looked it over Yes! She mentally gave herself a high five. Finally she had a problem she could solve: this was what she spent all of those years of training to do. The diabetes insipidus was so obvious when you looked at this data. All she had to do was to write one prescription! 1. Why are his kidneys so active so active at night? Note: diabetes insipidus is not diabetes, so the answer is not high blood sugar levels or an insulin deficiency. Diabetes merely high urine production. Look for a specific hormonal problem involving the pituitary. 2. It also turns out that he has unpredictable shock response, so that a small cut needing three stitches left him pale and in shock while breaking his left wrist in at least 15 place did not. What hormone could be involved? 3. If the pituitary is so important, and if Eric is not getting replacements of hormones the pituitary makes (except for ADH), why isn't he dead? To answer this question, thing through the cascade of events from hypothalamus to effect.

Explanation / Answer

1. His Kidneys are active at night because of abnormality in pituitary hormones. He appears to have acromegaly due to excessive telease of growth hormone. His kidneys were so active at night because his antidiuretic levels (found in the posterior pituitary) were damaged causing him to release water all the time instead of having the kidneys keep some.

2. Cortisone is involved in shock responses. The hormone that might be involved would be ACTH. The anterior pituitary controls the adrenal gland and it doesn’t have epinephrine and norepinephrine for stress response- no check and balance system. He might have low cortisone levels due to which shock responses are observed.

3. He is not dead though he had complications because the cascade of ADH triggers other glands and hormones. The hypothalamus controls the regulation of the pituitary glands hormones. The hypothalamus is compensating because it is releasing some of the hormones into the bloodstream.

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