1/18. Finger 'pebbles'. A dermatologic sign of diabetes mellitus.A 35-year-old obese man presented with a chief complaint of hand dryness of 5 years' duration. He was a store manager and denied exposure to chemicals, repetitive trauma, chronic irritation, and hard manual labor. However, he did admit to frequent hand washing. He had no itching or swelling in his hands, but on occasion he had tenderness in the dry areas. He had no personal or family history of diabetes, heart disease, or renal disease, and he stated that at his annual physical examination 6 months earlier, routine blood work was normal. He reported polyuria (every 2 hours), nocturia (five times per night), and polydipsia but no weakness, weight loss, visual changes, or neurosensory changes. Examination revealed xerosis of his hands and "pebbles" on the dorsal aspect of his fingers. The papules were most dense over the knuckles and interphalangeal joints (figures 1 through 3). He also had dozens of acrochordons (i.e., cutaneous papillomas, or skin tags) 1 to 4 mm in diameter on his neck, axilla, and groin. No other cutaneous lesions were noted. Specifically, there was no scleredema adultorum, necrobiosis lipoidica diabeticorum, acanthosis nigricans, bullae, or patchy pretibial pigmentation, although he did have several brown macules 1 to 5 mm in diameter on the sides of his lower legs. The macules had been present for years. Levels of hemoglobin A1c and glycated hemoglobin were 7.5% and 9.5%, respectively (normal, 4.4% to 5.9% and 5.0% to 7.3%). The patient was referred to his family physician, and his diabetes has been well controlled with insulin.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/18. Amputations associated with arteriovenous access.This study was performed to investigate the common characteristics of hemodialysis patients who need upper limb amputations. An index case was identified and involved questioning physicians and reviewing hospital and office records. Hemodialysis patients who have diabetes and leg amputations are at high risk for ischemic episodes that may lead to amputation of the arm, distal to the arteriovenous access site.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/18. Three patients with adrenal tumors having been treated simply for diabetes mellitus.Three patients with functional adrenal tumors, Cushing's syndrome, primary aldosteronism and pheochromocytoma, who underwent adrenalectomy and were subsequently cured, were studied. All these patients had been treated for diabetes for several years before the diagnosis of adrenal tumors. In each case the state of diabetes before and after surgery, including parameters of insulin secretion and insulin resistance, was compared to demonstrate how the adrenal disorder influenced the nature of diabetes. In the case of Cushing's syndrome the hypercortisolemia caused insulin resistance in the peripheral tissues. In the case of primary aldosteronism, excessive production of aldosterone diminished insulin secretion possibly through hypokalemia. pheochromocytoma affected both insulin secretion and insulin sensitivity through hypersecretion of catecholamines. In all these patients the adrenal tumors were found in clinical contexts other than management of diabetes itself. By careful retrospective review of these three patients' history, several important points that might have drawn the physician's attention to the underlying adrenal disorders were pointed out. These included past history of acute myocardial infarction with onset at unexpectedly young age in the case of Cushing's syndrome and unexpectedly high insulin resistance for the patient's body mass index in the case of pheochromocytoma.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/18. diabetes mellitus associated with atypical antipsychotic medications: new case report and review of the literature.BACKGROUND: Since the introduction of atypical antipsychotic medications, beginning with clozapine in 1990, several case reports in the psychiatric literature have suggested that they might be associated with new onset of diabetes mellitus as well as with diabetic ketoacidosis. methods: We report the case of a 38-year-old patient with schizophrenia who suddenly developed diabetes mellitus and ketoacidosis 12 months after starting olanzapine. Similar cases in the literature were found through a medline-assisted search using the key words "schizophrenia," "diabetes mellitus," "ketoacidosis," and "adverse drug reaction." RESULTS: Including this case, 30 patients have been reported in the literature to have developed diabetes or have lost diabetic control after starting clozapine, olanzapine, or quetiapine. Twelve of these 30 developed diabetic ketoacidosis. Two limited quantitative studies have added evidence toward this association. CONCLUSION: Although a causal relation has not been definitively proved, the number of cases reported in the literature suggests there might be an association between atypical antipsychotic medications and diabetes mellitus. Primary care physicians who care for patients with schizophrenia should be aware of this possible association.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/18. Postoperative management of the diabetic patient.Diabetic patients are at increased risk for adverse outcomes of surgery. These adverse outcomes are related to pre-existing complications of diabetes, especially atherosclerotic disease, nephropathy (and perhaps increased susceptibility to other renal toxins), and peripheral and autonomic neuropathy. hyperglycemia is associated with likely risks for poorer wound healing, increased susceptibility to infection, and probable loss of administered nutrients through glycosuria. Insulin use has the flexibility of timing and dose in the postoperative management of most diabetic patients. The combinations of intermediate-acting and long-acting insulins and short-acting insulins usually are related to the experience and preferences of the treating physicians and allied health professionals. Intravenous insulin (always R) may be limited to administration in the ICU because of the need for frequent blood glucose monitoring and rapidity of glucose response to intravenous insulin. The use of short-acting insulin analogues has been shown to work well as premeal insulin or for rapidly treating marked hyperglycemia in the outpatient setting. Meal delivery in the hospitalized patient may not be timed as precisely as in the home situation. nurses may be responsible for many patients. The rapid-acting analogues may be associated with increased risk for hypoglycemia in the hospitalized patient if insulin cannot be given immediately before a meal. These rapid-acting insulin analogues usually are limited to circumstances in which the patient can determine the dose and self-administer just before ingestion of the meal. The long-acting insulin analogues may not afford enough flexibility in many situations in which daily dosages changes are occurring in intermediate-acting and long-acting insulins. Oral glucose-lowering agent use in the postoperative state usually is limited to selected patients, including patients who have been on such agents before surgery, who have only mild elevations of blood glucose, who are able to ingest oral medications, and who do not have significant comorbid conditions (or significant risk for such conditions) that may be contraindications to use of such agents (see Table 3). Sulfonylureas and other insulin secretagogues (e.g., meglitinide, nateglinide) lower glucoses acutely. The risk for hypoglycemia is slightly less with the nonsulfonylurea agents. Efficacy and side effects limit the use of carbohydrase inhibitors for hospitalized patients. The glucose-lowering effects of biguanides and thiazolidinediones usually are not rapid enough for hospitalized patients who have never taken these medications. For patients who have been on a biguanide or thiazolidinedione before admission, these agents often are restarted in the postoperative period when oral intake of medications is possible and hepatic and renal function are stable. The hospital period affords an opportunity to review long-term management issues related to diabetes and its complications. Instruction on the importance of medical nutrition therapy, glycemic control, management of hypertension, dyslipidemia, and aspirin use as well as basic guidelines for foot care should be carried out during the hospitalization and at the time of discharge. Similarly, appropriate arrangements for medical nutrition therapy, general diabetes education (especially for newly diagnosed diabetic patients), and regular medical follow-up are important to ensure long-term, excellent surgical and medical outcomes.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/18. Individualizing insulin management. Three practical cases, rules for regimen adjustment.Many patients with diabetes become frustrated by the tedium of inflexible insulin instructions and unpalatable dietary restrictions. They lose confidence when their blood glucose levels fluctuate widely, and they may begin to think of themselves as "bad diabetics." Therefore, choosing the appropriate insulin and injection regimen for each patient is essential. Coordinated efforts by a concerned team of diabetes educators, dietitians, and physicians enhance the effectiveness of treatment. patients should be taught how to count carbohydrates, select foods with a low glycemic index, and adjust their insulin regimen by using sliding scales based on the 1500 or 1800 rule. Regular exercise and solid emotional support from family and friends also are helpful. By teaching patients the rules for insulin management, physicians can empower them to be much more actively involved in their own care and to lead healthier lives.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
7/18. The pulmonary physician in critical care. Illustrative case 1: cystic fibrosis.The case history of a patient with CF admitted to an ICU is presented and the appropriateness of intensive care management for patients with CF is discussed. Issues relevant to the ICU care of patients with CF are highlighted.- - - - - - - - - - ranking = 4keywords = physician (Clic here for more details about this article) |
8/18. diabetes mellitus and autonomic dysfunction after vacor rodenticide ingestion.A case of N-3 pyridylmethyl-N' 4 nitrophenyl urea (Vacor) rodenticide poisoning in a 52-year-old man is presented. Vacor is structurally related to alloxan and streptozotocin, agents that have been used extensively to produce diabetes mellitus in laboratory animals. Seven days after ingestion of Vacor, the patient presented in diabetic ketoacidosis complicated by postural hypotension and adynamic ileus. The patient recovered from ketoacidosis but has continued to require insulin. With infusion of arginine, glucagon rose from 185 to 650 pg./ml. and c-peptide from 0.5 to 3.4 ng./ml. Six weeks after onset of diabetes, no anti-islet-cell antibodies were detected. Muscle capillary basement membrane thickness on electron microscopy was found to be 1,918 /- 194 A. The absence of hyperglycemia after Vacor ingestion should not lead to complacency on the part of the attending physician. The patient must be observed closely for development of ketoacidosis and treated prophylactically with nicotinamide, the suggested antidote.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/18. diabetes mellitus and the kidney in adolescents.Diabetic nephropathy continues to be a major complication of both types I and II diabetes; renal disease in the two types of diabetes exhibits no major differences with regard to initiation, progression, or treatment. The increasing prevalence of type II diabetes among adolescents means that understanding diabetic nephropathy and its prevention and treatment strategies is increasingly important for physicians caring for this population. The most important prevention and treatment modalities for diabetic nephropathy are improved glycemic control and aggressive blood pressure control, beginning as soon as possible after the diagnosis of diabetes.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/18. A challenging patient, an innovative solution.This report of the management of a 28-year-old patient over 2 and a half years illustrates how interaction between psychosocial issues and physical symptoms complicates diagnosis and management. The case also highlights the challenges inherent in a large health care system with multiple health care professionals, clinics, and available resources. A "team model" approach is outlined as a useful strategy in such cases. Once problem areas are defined, a partnership agreement (contract) is recommended, which applies structure and limits to the physician-patient relationship. This contract calls for mutual trust, communication, and accountability while preventing excessive use of the health care system. Our patient and hospital system greatly benefited by this approach as evidenced by (1) a 60% decrease in medication costs, (2) markedly decreased ED visits and telephone calls, (3) successful treatment of depression and anxiety, and (4) a positive outcome on the patient's health.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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