Endocrinology

This 15-year-old boy presented with a 3-year history of gradual, bilateral breast enlargement. He was otherwise healthy and showed normal pubertal development.

The significant palmar erythema seen on the hands of a 60-year-old man with alcoholic cirrhosis is a sign of underlying chronic liver failure.

A 55-year-old woman, who had fairly well-controlled type 2 diabetes for 15 years, noticed a slow, progressive decrease in the visual acuity of her right eye during the past 6 to 8 weeks.

A mass in the neck of a 65-year-old woman had grown slowly and progressively during the last 5 years. The patient was otherwise asymptomatic; in particular, there was no heat or cold intolerance, irritability, weight loss, increased appetite, palpitations, lethargy, constipation, dysphagia, or dyspnea.

A healthy 31-year-old man was referred to a dermatologist with a diagnosis of tinea versicolor that did not respond to oral ketoconazole and topical selenium sulfide.

A 46-year-old man with diabetes presented for evaluation of gradual fingernail deterioration, which had failed to respond to several courses of griseofulvin and a recent 3-month course of daily terbinafine. The patient-who worked as a bartender-was otherwise healthy.

A 68-year-old woman was referred from an acute care clinic for evaluation of a persistent cellulitis. Ten days before, erythematous, pruritic plaques developed on her ankles; these slowly enlarged, and pustules formed. The patient denied fever or chills. Her past medical history was unremarkable, and conjugated estrogen, medroxyprogesterone acetate tablets, and multivitamins were the only medications and nutritional supplements she was taking.

This contorted hand of a 49-year-old man demonstrates Dupuytren's contracture, a disorder first described by Baron Guillaume Dupuytren in 1831. Although the condition may occur as a completely independent abnormality, it is commonly associated with chronic liver disease, diabetes mellitus, epilepsy, palmar fasciitis, carpal tunnel syndrome, rheumatoid arthritis, pulmonary tuberculosis, and alcoholism. This patient had a history of alcohol abuse.

A 30-year-old woman was brought to the hospital with syncope, bradycardia, and hypotension. For the past 6 years, she had vomited after eating meals and after occasional episodes of binge eating.

Highly pruritic, 2- to 4-mm, papular lesions with central ulceration erupted on the back of a 66-year-old woman. She had had 2 similar outbreaks in the past. The patient was taking conjugated estrogens, alprazolam, and alendronate.

After this 9-year-old boy complained of “growing too fast” during the past 1 to 2 years, his parents sought medical advice. He had no significant past medical history.

Three years ago, the young man pictured here was told that he might have acromegaly, but he ignored this warning. Now, at age 32, he consulted an endocrinologist because he realized his facial features and voice were becoming increasingly coarse. Soft-tissue swelling of his hands was also noted.

A 70-year-old man was brought from a nursing home to the emergency department with abdominal distention and vomiting of recent onset and a 2-day history of fever and abdominal pain. The patient had chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension. His gastric feeding tube, which had been placed via percutaneous endoscopic gastrostomy, was blocked.

A 32-year-old woman with insulin-dependent diabetes noted a painful erosion at the site of "the rose tattoo," which she had gotten 5 days before.

Abstract: Tuberculous meningitis has several different clinical presentations, including an acute meningitic syndrome simulating pyogenic meningitis, status epilepticus, stroke syndrome, and movement disorders. Cranial nerve palsies and seizures occur in about one third of patients, and vision loss is reported by almost 50%. The cerebrospinal fluid (CSF) typically shows moderately elevated levels of lymphocytes and protein and low levels of glucose. The demonstration of acid-fast bacilli in the CSF smear or Mycobacterium tuberculosis in culture confirms the diagnosis. CNS tuberculosis may also manifest as intracranial tuberculomas. The characteristic CT and MRI finding is a nodular enhancing lesion with a central hypointensity. Antituberculosis treatment should be initiated promptly when either tuberculous meningitis or tuberculoma is suspected. (J Respir Dis. 2005;26(9):392-400)

A 55-year-old man complains of fatigue. Although he sleeps 8 hours every night, he has to push himself to perform his usual daily activities. He has also experienced loss of libido and episodic impotence, which he ascribes to the fatigue.

Scaling patches that resist antifungals; an outbreak of red papules; a velvety,hyperpigmented rash--can you identify the disorders pictured here?

ABSTRACT: The management of chronic daily headache is difficult and complex. Those affected have a sensitive nervous system, and their predisposition for a low tolerance to sensory stimuli appears to be inherited. Under appropriate conditions, the equilibrium or balance between bombardment from painful stimuli and the regulatory systems that inhibit those stimuli is disrupted, allowing painful stimuli to become manifest at a greater intensity than in the nonmigraineur. Successful management depends on close adherence to nonpharmacologic approaches and pharmacologic regimens that desensitize the system and restore equilibrium. Comorbid conditions must be identified and treated as well.

A 62-year-old man was referred for consultation by his optometrist because of a suspicious-looking optic nerve head in the left eye. The patient felt that his vision was good, and he had no history of unusual eye findings. This was his first dilated eye examination.

A 72-year-old woman first noticed progressive enlargement of the maxillary area of her face 18 years earlier. She denied facial trauma and significant dental caries. Her medical history consisted of breast cancer managed by a mastectomy and type 2 diabetes mellitus of 3 years’ duration.

A 67-year-old woman with insulin-dependent diabetesmellitus and uncontrolled hyperglycemia complained offatigue and malaise. For 2 years, a draining ulcer hadbeen present on the bottom of her left foot.

ABSTRACT: The complexities of chronic nonmalignant pain and the contributions of psychosocial and environmental factors require assessment and treatment strategies that may go far beyond the use of analgesics. The first step is to rule out serious underlying conditions; determine the chronicity, quality, location, and intensity of the pain; assess aggravating environmental factors; and evaluate the patient's level of functioning. The pharmacologic regimen may include oral or topical analgesics, antidepressants, muscle relaxants, nerve stabilizers, and/or opioids. A comprehensive plan includes alternative modalities, such as physical and occupational therapy, stress management, relaxation techniques, and the treatment of comorbid conditions, including anxiety, depression, and sleep disorders. The optimal opioid regimen consists of methadone or a sustained-release opioid combined with a short-acting opioid for breakthrough pain.

A 23-year-old woman presents withweight loss, epigastric pain, abdominalfullness, and mild nausea. Shereports that she has had a slow-growingmass on her upper middle abdomen.She denies vomiting and doesnot have evidence of jaundice. Theonly significant finding in her medicalhistory is a myringotomy performedmany years earlier. She currentlytakes an oral contraceptive.

An 83-year-old woman is brought by her daughter for evaluation becauseof increasing confusion during the past few days. The patienthas early Alzheimer dementia, hypertension, and type 2 diabetes. She takes donepezil, 10 mg/d;lisinopril, 5 mg/d; and glipizide, 5 mg bid. She is unable to bathe and dress herself as well as previously,has been crying for no apparent reason, and has lost her appetite.

ABSTRACT: During the history taking, pay particular attention to pharmacologic and toxic exposures; among the medications and substances associated with tremor are ß-adrenergic agonists, stimulants, psychotropic agents, anticonvulsants, dopamine agonists, methylxanthine, and heavy metals. During the examination, observe the amplitude, frequency, and rhythm of the tremor. In contrast to physiologic tremors, which have low amplitude and high frequency, pathologic tremors typically have a higher amplitude and lower frequency. Tremors can be classified as resting, postural, or action. Resting tremor is almost always associated with other features of Parkinson disease, while postural and action tremors are prominent features of essential tremor. When essential tremor interferes with normal daily functioning, treatment is indicated. ß-Adrenergic antagonists, anticonvulsants, benzodiazepines, primidone, and nimodipine have been used in this setting. If these medications are ineffective, consider botulinum toxin A or surgery.

A 53-year-old man with type 2 diabetes mellitus and hypertension presented to the emergency department with pain in his left upper chest and back, neck, and shoulder. The pain increased with passive and active range of motion testing and decreased at rest. His physical examination was unremarkable except for restricted left shoulder movement and generalized tenderness in the left shoulder area.

Since adolescence, a 67-year old woman had had multiple nodular lesions on her body that were painful at times, particularly when pressure was applied. She reported that other family members, including her mother and brother, had similar lesions.

We have recently had an upsurge in children with type 1 diabetes at our gastroenterologyclinic for celiac screening.

ABSTRACT: To assess a child for overweight, begin by calculating his or her body mass index (BMI). Note that BMI is used differently in children than it is in adults. A child's BMI is plotted on a growth curve that reflects that child's age and gender. This yields a value-BMI-for-age-that provides a consistent measure across age groups. Children whose BMI-for-age is between 85% and 95% are at risk for becoming overweight. Any child whose BMI-for-age is 95% or more is considered overweight. The 2 main factors associated with overweight in children are poor eating habits and decreased physical activity. Recommend that children have at least 5 servings of fruits and vegetables a day. Children should engage in moderate physical activity for at least 60 minutes on most days of the week, and TV viewing and computer activities should be limited to no more than 2 hours a day.

ABSTRACT: The Studies of Left Ventricular Dysfunction (SOLVD) trials demonstrated that early intervention in congestive heart failure (CHF) improves survival. However, early CHF is mainly a clinical diagnosis based on New York Heart Association criteria and, until recently, no easy and inexpensive screening test existed. There are now several such tests that employ radioimmunoassays (RIAs) to measure cardiac peptides in a single plasma sample; results help determine the likelihood that CHF is present but do not definitively establish the diagnosis. The vessel dilator RIA is the most specific and sensitive for differentiating persons with mild CHF from healthy ones; intravenous administration of this cardiac peptide hormone has beneficial hemodynamic, diuretic, and natriuretic properties in persons who have CHF. Brain natriuretic peptide (BNP) measured by fluorescence immunoassay is useful in the emergency department, because a result may be obtained in as little as 15 minutes. This assay may indicate CHF; further tests are recommended to define the diagnosis. BNP increases with other causes of dyspnea, including pulmonary hypertension, pulmonary emboli, and renal failure, so it is not specific for CHF. BNP also increases with age, and measured values are higher in women than in men.