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__NOTOC__
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{{Autoimmune polyendocrine syndrome}}
{{Autoimmune polyendocrine syndrome}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}}{{Akshun}}


==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
The physical examination findings in autoimmune polyendocrine syndrome (APS)  may include [[hypotension]], [[bradycardia]], [[tetany]], dry [[skin]], coarse [[hair]], and [[muscle]] weakness depending upon the sub-type and the organ affected such as [[Adrenal Gland|adrenals]], [[thyroid]] or [[Pancreatic islets|pancreatic islet cells]]. Patients of APS usually appear [[Fatigue|fatigued]] and [[dehydrated]].


OR
==Physical Examination==
*The [[physical examination]] in autoimmune polyendocrine syndrome is variable and depends upon the sub-type and the organ involved.
*APS can involve multiple organs and the most common conditions associated with APS such as [[Addison's disease]], [[type 1 diabetes mellitus]] and [[hypoparathyroidism]] are described below.
===Addisons's disease===
The patient may be [[dehydrated]] and [[lethargic]].<ref name="pmid23633816">{{cite journal |vauthors=Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S |title=Addison's disease |journal=Contemp Clin Dent |volume=3 |issue=4 |pages=484–6 |year=2012 |pmid=23633816 |pmc=3636818 |doi=10.4103/0976-237X.107450 |url=}}</ref>
 
'''Vitals'''
* [[Hypotension|Low blood pressure]]
* [[Orthostatic hypotension]]
* [[Fever]]
 
'''Skin'''
* [[Hyperpigmentation|Hyperpigmented]] [[skin]] and [[mucous membranes]] - darkening ([[hyperpigmentation]]) of the [[skin]], including areas not exposed to the sun; characteristic sites are [[skin]] creases (e.g. of the hands), nipples, and the inside of the cheek ([[buccal]] [[Mucosal|mucosa]]), old scars may also darken.
* [[Vitiligo]] may be present.
* Absence of [[axillary]] and [[pubic]] hair in [[females]] as a result of loss of [[adrenal]] [[androgens]].
* [[Pallor]] may be present.
 
'''Neck'''
* [[Goiter]] may be present.
 
'''Extremities'''
* [[Weakness]]
 
'''Neurologic'''
* [[Confusion]] may be present
* [[Seizures]] may be present.
 
===Type 1 diabetes mellitus===
[[Physical examination]] of type 1 DM include:<ref>http://www.aafp.org/afp/2005/0501/p1705.pdf</ref><ref>Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016</ref><ref>http://spectrum.diabetesjournals.org/content/15/1/28</ref><ref>{{Cite web|url=http://care.diabetesjournals.org/content/26/suppl_1/s109|title=ADA|last=|first=|date=|website=|publisher=|access-date=}}</ref>
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Examination findings
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Classic new onset
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Diabetic ketoacidosis
|-
|'''Appearance of patient'''
|Patient is usually well appearing
|Patients are ill appearing, may be confused or in state of [[coma]]
|-
|'''[[Vital signs]]'''
|[[Pulse rate]]- Normal
[[Temperature]]- Normal
 
[[Blood pressure]]- Normal
 
[[Respiratory rate]]- Normal
 
[[Oxygen saturation]]- Normal
 
[[Blood glucose]] level- Elevated
|[[Pulse rate]]- [[Tachycardia]] with regular rhythm, weak volume
Temperature- Normal or elevated or [[hypothermia]]
 
[[Blood pressure]]- Low [[blood pressure]]
 
[[Respiratory rate]]-
* [[Tachypnea]]
* [[Kussmaul respirations]] may be present in case of late presentation
[[Oxygen saturation]]- usually normal but some cases may have low [[oxygen saturation]] 
 
[[Blood glucose]] level- markedly elevated
 
|-
|[[Skin|'''Skin''']]
|[[Skin]] examination is usually normal, but in some cases may reveal dry [[skin]]
|Poor [[skin]] [[turgor]] because of [[dehydration]]
|-
|'''HEENT'''
|HEENT examination is usually normal, in some cases [[eye]] examination may reveal opacity of [[lens]] ([[cataract]])
|Dry [[mucous membrane]], [[eyes]] may appear sunken because of [[dehydration]]
|-
|'''Neck'''
|[[Neck]] examination is  normal
|[[Neck]] examination is normal
|-
|[[Lungs|'''Lungs''']]
|[[Lung]] examination is normal
|[[Lung]] examination is usually normal, but in some cases [[lung]] examination may reveal underlying triggering causes of [[diabetic ketoacidosis]] eg: [[pneumonia]]
|-
|[[Heart|'''Heart''']]
|[[Heart]] examination is normal (S1 + S2 + 0)
|[[Heart]] examination is usually normal (S1 + S2 + 0)
|-
|[[Abdomen|'''Abdomen''']]
|[[Abdominal]] examination is normal
|[[Abdominal]] [[tenderness]] may be elicited
|-
|'''Back'''
|Back examination is normal
|Back examination is usually normal
|-
|[[Genitourinary|'''Genitourinary''']]
|[[Genitourinary]] examination is usually normal
|[[Genitourinary]] examination is usually normal
|-
|[[Extremities|'''Extremities''']]
|Examination of [[extremities]] is usually normal, some cases may elicit finding of decreased sensation in the [[extremities]]
|Examination of [[extremities]] is usually normal
|-
|[[Neuromuscular|'''Neuromuscular''']]
|[[Neuromuscular]] examination is usually normal
|[[Neuromuscular]] examination is usually normal
|}


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
===Hypoparthyroidism===
*[[Physical examination]] of patients with [[hypoparathyroidism]] is usually due to [[hypocalcemia]].<ref name="pmid28138323">{{cite journal |vauthors=Abate EG, Clarke BL |title=Review of Hypoparathyroidism |journal=Front Endocrinol (Lausanne) |volume=7 |issue= |pages=172 |year=2016 |pmid=28138323 |pmc=5237638 |doi=10.3389/fendo.2016.00172 |url=}}</ref><ref name="pmid18535072">{{cite journal |vauthors=Cooper MS, Gittoes NJ |title=Diagnosis and management of hypocalcaemia |journal=BMJ |volume=336 |issue=7656 |pages=1298–302 |year=2008 |pmid=18535072 |pmc=2413335 |doi=10.1136/bmj.39582.589433.BE |url=}}</ref>
*The presence of [[tetany]] on [[physical examination]] is diagnostic of [[hypocalcemia]] which is commonly caused by [[hypoparathyroidism]].<ref>{{cite book |last1=Schafer |first1=AL |last2=Shoback |first2=DM |editor-last1=De Groot |editor-first1=LJ |editor-last2=Chrousos |editor-first2=G |editor-last3=Dungan |editor-first3=K  |display-editors=etal |date= |title=Hypocalcemia: Diagnosis and Treatment. [Updated 2016 Jan 3]. |url=https://www.ncbi.nlm.nih.gov/books/NBK279022/ |location= Endotext [Internet]. |publisher=South Dartmouth (MA): MDText.com, Inc.; 2000-. |page= |isbn= |author-link= }}</ref>
*The presence of [[Chvostek's sign]] and [[Trousseau's sign|Trousseau's sign]] on [[physical examination]] is highly suggestive of [[hypocalcemia]] which is commonly caused by  [[hypoparathyroidism]].<ref name="pmid18650515">{{cite journal |vauthors=Shoback D |title=Clinical practice. Hypoparathyroidism |journal=N. Engl. J. Med. |volume=359 |issue=4 |pages=391–403 |year=2008 |pmid=18650515 |doi=10.1056/NEJMcp0803050 |url=}}</ref>


OR
'''Appearance of the Patient:'''
*Patients with [[hypoparathyroidism]] usually have [[neuromuscular]] [[irritability]] and may appear [[dysphoric]].


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
'''Vital Signs:'''
*[[Bradycardia]]


OR
'''Skin:'''


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Careful examination of [[skin]] around [[neck]] should be done for a possible [[surgical]] scar.
==Physical Examination==
*The physical examination in autoimmune polyendocrine syndrome is variable and depends upon the subtype and the involved organ.
*APS can involve a number of organs and the most common conditions associated with APS are described below.


Common signs present are:
*[[Dry skin]]
*Coarse [[hair]]


'''HEENT:'''


===Appearance of the Patient===
Some patients may have:
*Patients with [disease name] usually appear [general appearance].
*Subcapsular [[cataracts]]
*[[Papilledema]]<ref name="pmid3690435">{{cite journal |vauthors=Sheldon RS, Becker WJ, Hanley DA, Culver RL |title=Hypoparathyroidism and pseudotumor cerebri: an infrequent clinical association |journal=Can J Neurol Sci |volume=14 |issue=4 |pages=622–5 |year=1987 |pmid=3690435 |doi= |url=}}</ref>


===Vital Signs===


*High-grade / low-grade fever
'''Lungs:'''
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
Some patients may have:
*[[Cyanosis]]  
*[[Dyspnea]]
*[[Jaundice]]
*[[Wheeze|Wheezing]]
* [[Pallor]]
* Bruises


<gallery widths=150px>
'''Heart:'''


UploadedImage-01.jpg | Description {{dermref}}
Some patients may have:
UploadedImage-02.jpg | Description {{dermref}}
*[[Palpitation]]
*Signs of [[congestive heart failure]] such as [[fluid overload]] ([[S3 gallop]])<ref name="pmid4014262">{{cite journal |vauthors=Levine SN, Rheams CN |title=Hypocalcemic heart failure |journal=Am. J. Med. |volume=78 |issue=6 Pt 1 |pages=1033–5 |year=1985 |pmid=4014262 |doi= |url=}}</ref>


</gallery>
* Signs of [[cardiomyopathy]]<ref name="pmid1633370">{{cite journal |vauthors=Kudoh C, Tanaka S, Marusaki S, Takahashi N, Miyazaki Y, Yoshioka N, Hayashi M, Shimamoto K, Kikuchi K, Iimura O |title=Hypocalcemic cardiomyopathy in a patient with idiopathic hypoparathyroidism |journal=Intern. Med. |volume=31 |issue=4 |pages=561–8 |year=1992 |pmid=1633370 |doi= |url=}}</ref>


===HEENT===
'''Abdomen:'''
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
Some patients may have:
*[[Jugular venous distension]]
* [[Dysphagia]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
'''Neuromuscular:'''
* Asymmetric chest expansion / Decreased chest expansion
*Lungs are hypo/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
Most common presentation is due to [[neuromuscular]] irritability. It present as:
*Chest tenderness upon palpation
*[[Tetany|Tetany]]
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Chvostek's sign]]: [[Facial]] twitching, especially around the [[mouth]]. It is elicited by tapping the [[cheek]] (2 cm anterior to the earlobe below the [[zygomatic process]]) over the path of the [[facial nerve]]. Ipsilateral [[twitching]] of the upper [[lip]] is considered as positive sign.
*[[Heave]] / [[thrill]]
*[[Trousseau's sign]]: Painful [[carpal]] [[spasm]]. It is elicited by inflating a [[blood pressure]] cuff around the arm to a pressure 20 mm Hg above obliteration of the [[Radial artery|radial]] [[pulse]] for 3-5 minutes.
*[[Friction rub]]
*[[Tingling]], burning, and/or [[numbness]] in the [[Fingertip|fingertips]], [[Toe|toes]] and [[lips]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Muscle weakness]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope


===Abdomen===
Some patients may have [[extrapyramidal]] signs (due to [[calcification]] of [[basal ganglia]]):<ref name="pmid22224190">{{cite journal |vauthors=Basak RC |title=A case report of Basal Ganglia calcification - a rare finding of hypoparathyroidism |journal=Oman Med J |volume=24 |issue=3 |pages=220–2 |year=2009 |pmid=22224190 |pmc=3251182 |doi=10.5001/omj.2009.44 |url=}}</ref>
*[[Abdominal distention]]  
*[[Parkinsonism]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Choreoathetosis]]
*[[Rebound tenderness]] (positive Blumberg sign)
*[[Dystonia]]
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*[[Oculogyric crisis]]
*Guarding may be present
*[[Hemiballismus]]
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
'''Psychiatric:'''
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
Some patients may have [[psychiatric]] manifestations:<ref name="pmid11834431">{{cite journal |vauthors=Arlt W, Fremerey C, Callies F, Reincke M, Schneider P, Timmermann W, Allolio B |title=Well-being, mood and calcium homeostasis in patients with hypoparathyroidism receiving standard treatment with calcium and vitamin D |journal=Eur. J. Endocrinol. |volume=146 |issue=2 |pages=215–22 |year=2002 |pmid=11834431 |doi= |url=}}</ref><ref name="pmid25772947">{{cite journal |vauthors=Lin KF, Chen KH, Huang WL |title=Organic anxiety in a woman with breast cancer receiving denosumab |journal=Gen Hosp Psychiatry |volume=37 |issue=2 |pages=192.e7–8 |year=2015 |pmid=25772947 |doi=10.1016/j.genhosppsych.2015.01.007 |url=}}</ref>
*A pelvic/adnexal mass may be palpated
*[[Anxiety]]
*Inflamed mucosa
*[[Depression]]
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
*[[Irritability]]
*[[Psychosis]]
*[[Anxiety]]


===Neuromuscular===
'''Extremities:'''
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
Some patients may have:
*[[Clubbing]]  
*[[Edema]] due to [[cardiac]] dysfunction
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==

Latest revision as of 14:43, 30 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]

Overview

The physical examination findings in autoimmune polyendocrine syndrome (APS) may include hypotension, bradycardia, tetany, dry skin, coarse hair, and muscle weakness depending upon the sub-type and the organ affected such as adrenals, thyroid or pancreatic islet cells. Patients of APS usually appear fatigued and dehydrated.

Physical Examination

Addisons's disease

The patient may be dehydrated and lethargic.[1]

Vitals

Skin

Neck

Extremities

Neurologic

Type 1 diabetes mellitus

Physical examination of type 1 DM include:[2][3][4][5]

Examination findings Classic new onset Diabetic ketoacidosis
Appearance of patient Patient is usually well appearing Patients are ill appearing, may be confused or in state of coma
Vital signs Pulse rate- Normal

Temperature- Normal

Blood pressure- Normal

Respiratory rate- Normal

Oxygen saturation- Normal

Blood glucose level- Elevated

Pulse rate- Tachycardia with regular rhythm, weak volume

Temperature- Normal or elevated or hypothermia

Blood pressure- Low blood pressure

Respiratory rate-

Oxygen saturation- usually normal but some cases may have low oxygen saturation

Blood glucose level- markedly elevated

Skin Skin examination is usually normal, but in some cases may reveal dry skin Poor skin turgor because of dehydration
HEENT HEENT examination is usually normal, in some cases eye examination may reveal opacity of lens (cataract) Dry mucous membrane, eyes may appear sunken because of dehydration
Neck Neck examination is normal Neck examination is normal
Lungs Lung examination is normal Lung examination is usually normal, but in some cases lung examination may reveal underlying triggering causes of diabetic ketoacidosis eg: pneumonia
Heart Heart examination is normal (S1 + S2 + 0) Heart examination is usually normal (S1 + S2 + 0)
Abdomen Abdominal examination is normal Abdominal tenderness may be elicited
Back Back examination is normal Back examination is usually normal
Genitourinary Genitourinary examination is usually normal Genitourinary examination is usually normal
Extremities Examination of extremities is usually normal, some cases may elicit finding of decreased sensation in the extremities Examination of extremities is usually normal
Neuromuscular Neuromuscular examination is usually normal Neuromuscular examination is usually normal

Hypoparthyroidism

Appearance of the Patient:

Vital Signs:

Skin:

Careful examination of skin around neck should be done for a possible surgical scar.

Common signs present are:

HEENT:

Some patients may have:


Lungs:

Some patients may have:

Heart:

Some patients may have:

Abdomen:

Some patients may have:

Neuromuscular:

Most common presentation is due to neuromuscular irritability. It present as:

Some patients may have extrapyramidal signs (due to calcification of basal ganglia):[13]

Psychiatric:

Some patients may have psychiatric manifestations:[14][15]

Extremities:

Some patients may have:

References

  1. ↑ Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S (2012). "Addison's disease". Contemp Clin Dent. 3 (4): 484–6. doi:10.4103/0976-237X.107450. PMC 3636818. PMID 23633816.
  2. ↑ http://www.aafp.org/afp/2005/0501/p1705.pdf
  3. ↑ Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016
  4. ↑ http://spectrum.diabetesjournals.org/content/15/1/28
  5. ↑ "ADA".
  6. ↑ Abate EG, Clarke BL (2016). "Review of Hypoparathyroidism". Front Endocrinol (Lausanne). 7: 172. doi:10.3389/fendo.2016.00172. PMC 5237638. PMID 28138323.
  7. ↑ Cooper MS, Gittoes NJ (2008). "Diagnosis and management of hypocalcaemia". BMJ. 336 (7656): 1298–302. doi:10.1136/bmj.39582.589433.BE. PMC 2413335. PMID 18535072.
  8. ↑ Schafer, AL; Shoback, DM. De Groot, LJ; Chrousos, G; Dungan, K; et al., eds. Hypocalcemia: Diagnosis and Treatment. [Updated 2016 Jan 3]. Endotext [Internet].: South Dartmouth (MA): MDText.com, Inc.; 2000-.
  9. ↑ Shoback D (2008). "Clinical practice. Hypoparathyroidism". N. Engl. J. Med. 359 (4): 391–403. doi:10.1056/NEJMcp0803050. PMID 18650515.
  10. ↑ Sheldon RS, Becker WJ, Hanley DA, Culver RL (1987). "Hypoparathyroidism and pseudotumor cerebri: an infrequent clinical association". Can J Neurol Sci. 14 (4): 622–5. PMID 3690435.
  11. ↑ Levine SN, Rheams CN (1985). "Hypocalcemic heart failure". Am. J. Med. 78 (6 Pt 1): 1033–5. PMID 4014262.
  12. ↑ Kudoh C, Tanaka S, Marusaki S, Takahashi N, Miyazaki Y, Yoshioka N, Hayashi M, Shimamoto K, Kikuchi K, Iimura O (1992). "Hypocalcemic cardiomyopathy in a patient with idiopathic hypoparathyroidism". Intern. Med. 31 (4): 561–8. PMID 1633370.
  13. ↑ Basak RC (2009). "A case report of Basal Ganglia calcification - a rare finding of hypoparathyroidism". Oman Med J. 24 (3): 220–2. doi:10.5001/omj.2009.44. PMC 3251182. PMID 22224190.
  14. ↑ Arlt W, Fremerey C, Callies F, Reincke M, Schneider P, Timmermann W, Allolio B (2002). "Well-being, mood and calcium homeostasis in patients with hypoparathyroidism receiving standard treatment with calcium and vitamin D". Eur. J. Endocrinol. 146 (2): 215–22. PMID 11834431.
  15. ↑ Lin KF, Chen KH, Huang WL (2015). "Organic anxiety in a woman with breast cancer receiving denosumab". Gen Hosp Psychiatry. 37 (2): 192.e7–8. doi:10.1016/j.genhosppsych.2015.01.007. PMID 25772947.

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