1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.2.1. pituitary gland
1.2.1.1. anatomy
1.2.1.2. physiology
1.2.2. growth hormone
1.2.2.1. physiology
1.2.2.2. dysfunction
1.2.2.2.1. tumors ??
1.2.3. growth parameter chart
1.3. 30 minutes
2. Step 8
2.1. Diagnostic decision
2.1.1. pituitary tumor casing hypopituitarism
2.2. Mechanism
2.2.1. tu,or compressing the anterior pituitary leads to non-secerating pituitary hormones
2.3. Presentation
2.3.1. growth retardation, visual feild abnormality, headache and reduced sexual presentation
2.4. Supporting data
2.4.1. MRI showed a mass in the pituitary gland compressing the optic chiasm
2.4.2. the basal hormone showed reduced T4, LH FSH and IGF! levels
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complaint
3.1.1.1. shoortness of stature
3.1.1.2. poor performance in school
3.1.1.3. noticed by mother to be short at early primary school age
3.1.1.4. when presented to the clinic he reassure her that he will gain weight and his height will increase
3.1.1.5. intermittent headache .. in last few months it become progressive but it respond to panadol
3.1.1.6. has trouble to see class board .. haven't seen by ophthalmolgist
3.1.1.7. a year ago his performance detriorated because of the vision problem
3.1.1.8. he has never been sporty boy but participate in organization .. recently he stopped participation because he is fatigue
3.1.1.9. he gained 4 cm in height during the last two years
3.1.2. Previous medical / surgical history
3.1.2.1. normal pregnancy .. born preetch
3.1.2.2. weight was 2.7 kg and the length 50 cm
3.1.2.3. no chronic disease .. no previous disease .. no trauma
3.1.2.4. no surgeries
3.1.3. Drug history / allergy
3.1.3.1. negative
3.1.4. Family history
3.1.4.1. youngest of 3 .. sister is 15 yrs her height is 160 .. the brother is 16 and his height is 170
3.1.4.2. the mother is 160 cm .. the father is 165 cm
3.1.5. Social / occupational history
3.1.5.1. have couple of friend and he enjoy his time with them
3.1.5.2. does not like meet .. eat vegetables .. keen on some fast foods
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. vitals
3.1.7.1.1. bp 80/60
3.1.7.1.2. pulse is 60
3.1.7.1.3. ht is 129 cm below the third percentile
3.1.7.1.4. wt is 40 kg below the 25th percentile
3.1.7.1.5. normal head circumference
3.1.7.2. inspection
3.1.7.2.1. younger than his actual age
3.1.7.2.2. shorter than his age
3.1.7.2.3. no dysmorphic features
3.1.7.3. visual testing
3.1.7.3.1. reduced temporal field especially in the left
3.1.7.3.2. visual acuity was 6/5 in the right .. in the left 6/36
3.1.7.3.3. fundscopy revealed a pale left optic disk
3.1.7.4. cardiovascular
3.1.7.4.1. normal no murmur .. sounds heard well
3.1.7.5. reproductive
3.1.7.5.1. testis were 3 ml prader orchidometer (abnormal)
3.1.7.5.2. no pubic hair
3.1.7.6. repiratory and GI are normal
3.1.8. tests results
3.1.8.1. bone age 10.5 years
3.1.8.2. T4, LH, FSH and IGF-1 are reduced .. TSH is normal (should be increased in this case)