Endocrinology

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.

A 54-year-old man with a history of type 2 diabetes, hypertension, and coronaryartery disease with angina presents to the physician’s office withchest pain. The pain began 3 hours earlier and is associated with diaphoresisand dyspnea. Examination results are unremarkable, except for diaphoresis.A 12-lead ECG reveals normal sinus rhythm with large R waves and horizontalST-segment depression in leads V1 through V3. The patient is given nitroglycerin,aspirin, heparin, morphine, and a &#946-blocker for noninfarction acutecardiac ischemia and transferred to the local emergency department (ED).

A 41-year-old woman presents as a new patient, with complaintsof chest pain and palpitations that occur intermittentlyand are not associated with activity, meals, or position.She says these symptoms have been present forsome time, and she expresses frustration that her previousphysician was unable to find their cause or to amelioratethem.

For about 3 to 4 months, a 53-year-old man has had gradually worsening footdiscomfort. He describes the discomfort as a burning sensation accompaniedby numbness and tingling. Initially, these symptoms were present only in hisfeet, but for several weeks they have involved both ankles as well. Althoughthe discomfort is always present, it is occasionally aggravated by the bed coversor by heavy woollen socks. The patient has no skin lesions, motor symptoms,or other abnormalities of his legs or feet.

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.

The incidence of hypertension, diabetes, certain types ofcancer, and other chronic diseases is disproportionatelyhigher in African Americans than in white Americans. Thestatistics presented in the Table illustrate the magnitudeof this disparity. For other diseases, such as breast cancer,the incidence is lower but mortality is higher in AfricanAmericans.

In recent years, 2 large randomized,controlled studies have documentedthe efficacy of the anticonvulsantgabapentin in the management ofpainful diabetic neuropathy (PDN)1and post-herpetic neuralgia (PHN).2Although vastly different in origin,these 2 neuropathies have exhibitedsome similarities in their response totherapeutic agents of various classes.The discovery that yet another typeof pharmaceutical is useful in treatingpain from either PDN or PHN hasraised questions about the similaritiesand differences in the managementof these 2 painful neuropathicsyndromes.

A 70-year-old man complains of a sudden, painless loss ofvision in the left eye that occurred several hours earlier. He denies traumaand previous visual disturbances. His history is significant for peripheralvascular disease and type 2 diabetes mellitus.

A 67-year-old man with poorly controlled type 2 diabetes mellitus presents withleg pain and swelling that began 3 days earlier. Multiple ulcers are noted at thelateral malleolus. His temperature is 38.9°C (102.1°F). Right lower extremitycellulitis is diagnosed, blood samples are taken for culture, and the patient ishospitalized.

An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.

What caused these linear, grouped, pigmented papules on a child's back? These symmetrical hyperpigmented patches on a man's face? Test your diagnostic skills.