Endocrinology

A 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.

A preoperative evaluation performed shortly before a 66-year-old man is scheduledto undergo coronary artery bypass graft (CABG) surgery reveals a peripheralblood leukocyte count of 23,500/μL with 28% neutrophils, 70% lymphocytes,and 2% monocytes. The patient’s hemoglobin level is 14.5 g/dL; plateletcount is 265,000/μL.

Dr David Kaplan presented the case of a teenager with aphthous stomatitis in aDermclinic feature.

My patient is a 70-year-old man who has had several episodesof cellulitis in his right thigh; he does not have diabetes.After the third episode, a 1-cm subcutaneous mass was excisedabove the area of recurrent cellulitis.

A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.

My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled.

Patients with benign essential tremoror Graves disease can have tremorsso fine that they are easily missed onphysical examination.

I recently diagnosed type 2 diabetes mellitus in a 33-year-old man who has no diabeticsymptoms, proteinuria, or evidence of nephropathy. His blood pressure is low(100/60 mm Hg).

My patient is a 78-year-old man who complains of severe exhaustion, lack of energy,and hot flashes.

A 55-year-old constructionworker who spends a gooddeal of time outdoors has had occasionalblurred vision and an irritatedeyelid for several days. He has wellcontrolleddiabetes and hypertension.Which of these conditions doyou suspect?

To facilitate the swallowing movementsthat are key to the examinationof neck swellings-particularlythose of the thyroid gland-give thepatient a full cup of water and askhim or her to drink it slowly whileyou examine the neck.

When you examine patients withGraves disease, be careful when youpalpate the enlarged thyroid gland.

In his article, “Subclinical Hypothyroidism: When to Treat, When to Watch?”(CONSULTANT, April 1, 2004, page 533), Dr Vahab Fatourechi notes that thereis some evidence that subclinical hypothyroidism has adverse effects on cardiovascularfunction that may contribute to left ventricular systolic dysfunction with effort.

When should children who have a family history of either type 1 or type 2 diabetesbe screened for prediabetes?

A 38-year-old overweight woman presents with an asymptomatic rash ofat least 2 months’ duration that had not responded to a combinationcorticosteroid/antifungal agent. She has mild hypertension and type 2 diabetesmellitus that is being managed with diet and exercise. She is otherwisehealthy.

When a patient with diabetes presentswith a foot wound, prompt and aggressiveintervention is required topromote healing and to prevent progressionthat could lead to a leg amputation.Fortunately, the majority ofdiabetic foot wounds heal rapidly withlittle difficulty.

My patient is a 10-year-old boy with asthma. After an exacerbation of his asthmawas treated with albuterol and solumedrol, his blood glucose level was 250 mg/dLwith 1+ glucosuria (no ketones).

Men and women with diabetes are 2 to 4 times more likelythan other persons to die of complications of cardiovasculardisease (CVD). Solid evidence from primary andsecondary prevention trials has prompted the AmericanDiabetes Association to recommend low-dose aspirin therapyfor patients with diabetes who either have or are athigh risk for CVD (Table).

A 64-year-old woman complainsof neck fullness that has increased inthe last few months. She has occasionaldyspnea but denies fever, cough, andhemoptysis. Hypertension is well-controlledwith propranolol.

Is there evidence that treating elevated fasting glucose levels or impairedglucose tolerance, from early in pregnancy until term, improves outcomes(ie, fewer cesarean deliveries, fewer macrosomic babies, fewer patients in whompreeclampsia develops, fewer mothers who subsequently require insulin)?

An 84-year-old man complains of worsening angina pectoris that started3 months earlier. The patient has had aortic stenosis for about 10 years. Healso has diabetes, which is controlled with oral agents.

Long-standing chorioretinal scarring in both eyes didnot affect a 67-year-old woman’s vision. The scars wereroundish, irregular, and yellowish white with interior pigmentation(A and B).

A 67-year-old woman has had an ulcer on her left heel for at least several weeks.She applied a homemade dressing and cut her shoes to try to relieve pressureon the ulcer; however, in the past week, areas around the ulcer have becomepainful. These areas, as well as the dorsum of the foot, are red and swollen.

For several months, a 26-year-old man has had persistent bumps on his scalpand the back of his neck. Some hair loss has also occurred at the site.

In his article “High-Risk Hypertensive Patients: How to Optimize Therapy UsingACE Inhibitors and ARBs” (CONSULTANT, October 2003, page 1390), Dr JanBasile recommends angiotensin-converting enzyme (ACE) inhibitors for patientswith type 1 diabetes with or without hypertension, whether or not nephropathyis present.

A 69-year-old woman is broughtto the emergency department(ED) after a head-on collision in whichshe sustained injury to the right sideof the chest and the left ankle in additionto a laceration on her left forearm.She possibly had a transient loss ofconsciousness, but in the ED she canrecall all the events of the car accident.She complains of pain in the chestand ankle.

A 57-year-old African American man comes to your office because he isconcerned about his blood pressure (BP). When it was measured at a healthfair a month earlier, it was 157/96 mm Hg; a week later at a clinic it was162/97 mm Hg. Now his resting BP is 166/101 mm Hg.

In her response to a reader’s question about clot prevention in a patient with systemiclupus erythematosus (SLE) and anticardiolipin antibody syndrome,Dr Bonnie Bermas recommends warfarin (CONSULTANT, September 15, 2003,page 1329).

Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.

Heart failure statistics are daunting:550,000 new cases each year, a 1-yearmortality rate of nearly 20%, and annualdirect and indirect costs that total $24.3billion.1 The diverse etiology of heartfailure and the complex, progressivecourse of the disease can make treatmentdecisions daunting as well.