1/9. 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 = physical examination, physical (Clic here for more details about this article) |
2/9. A patient with diabetes mellitus and severe arterial embolism.An 89-year-old man with diabetes mellitus was admitted to the hospital because of a low-grade fever and a disturbance in consciousness. He had been diagnosed as having diabetes mellitus at the age of 22 years and had been taking oral hypoglycemic drugs for 16 years at least. A few days before admission, a loss of appetite was noticed by his family; he developed a stupor on the day of admission. On physical examination, his lower extremities were pale and his skin temperature was low. Laboratory tests showed an increase in his white blood cell count and his blood culture was positive for staphylococcus aureus. An MRI showed that the abdominal aorta was totally occluded beneath the renal arteries, and no significant collateral circulation was observed. He was given antibiotics and anticoagulants, but his general condition continued to worsen. Laboratory tests showed renal failure and liver dysfunction, indicating multi-organ failure. On the 24th day of admission, he died of respiratory and heart failure. An autopsy showed the aorta to be totally occluded beneath the renal arteries by an embolism; atherosclerotic changes were rather mild. Acute plaque change on the surface of the aorta may have induced the sudden development of emboli in the aorta.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/9. Neonatal diabetes with hyperchylomicronemia.Neonatal diabetes mellitus (NDM) is defined as hyperglycemia occurring in the first few weeks of life. It can be either transient (TNDM) or permanent (PNDM). A 25 days old newborn was brought to the hospital with restlessness, respiratory depression and cyanosis. He was born at term with a birth weight of 2,000 g. There was no consanguinity between his parents. His physical examination findings were as follows: Weight and height were under 3th percentile, he was hypoactive and dehydrated. serum glucose level was 800 mg/dl; c-peptide was 0.41 ng/ml. Upon investigation for dyslipidemia in association with his neonatal diabetes, hyperchylomicronemia was found both in the patient and his father. pancreatitis, anemia and cholestasis were also observed. insulin treatment was started for his diabetes together with a special diet for dyslipidemia. At the end of 28 months of follow-up, dyslipidemia has resolved but the need for insulin therapy was still existing. However, TNDM was considered in differential diagnosis because he was small for gestational age (SGA) at birth and his symptoms had started at the 25th day of the neonatal period. Delayed recovery from insulin dependency brought out the possibility of PNDM. Furthermore, neonatal diabetes combined with hypechylomicronemia is a rare clinical picture. Reported cases of NDM with different clinical evaluation will help to better understanding of this disorder.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/9. Rabson-Mendenhall syndrome.Rabson-Mendenhall syndrome is characterized by growth retardation, dysmorphisms, lack of subcutaneous fat, acanthosis nigricans, enlarged genitalia, hirsutism, premature and dysplastic dentition, coarse facial features, paradoxical fasting hypoglycemia and post-prandial hyperglycemia, extreme hyperinsulinemia and pineal hyperplasia. We describe a six-month-old female child with physical features suggestive of the Rabson-Mendenhall syndrome. The child also had medullary nephrocalcinosis.- - - - - - - - - - ranking = 0.091147444510669keywords = physical (Clic here for more details about this article) |
5/9. 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 = 0.091147444510669keywords = physical (Clic here for more details about this article) |
6/9. Familial insulin-resistant diabetes secondary to an affinity defect of the insulin receptor.We describe three siblings with a mild diabetes mellitus in combination with acanthosis nigricans and multiple minor physical abnormalities. fasting plasma insulin was elevated up to 100-fold as compared with normal values, and the diabetes was classified as insulin resistant. insulin-binding studies on erythrocytes, monocytes, and cultured fibroblasts disclosed an abnormally reduced binding capacity, as compared with that of healthy controls, which was most prominent at low concentrations of insulin. Scatchard analysis on erythrocytes of the three patients revealed a normal number of total insulin-binding sites per cell, but a complete lack of insulin binding to the high-affinity receptor component. The findings are consistent with the assumption of two genetically distinct types of insulin receptors.- - - - - - - - - - ranking = 0.091147444510669keywords = physical (Clic here for more details about this article) |
7/9. Educating the elderly diabetic at a day hospital.Elderly people who develop diabetes should have an individual programme of education, tailor-made after assessing their physical and social needs. Avoid bombarding them with too much information, much of which may be inappropriate and even frightening. The Day Hospital, with its multidisciplinary team of nurse, doctor, social worker, physiotherapist and occupational therapist, is an ideal setting for educating and supervising the elderly diabetic. Ongoing assessment is provided through regular monitoring, education through games and group discussions, and home visits where necessary- - - - - - - - - - ranking = 0.091147444510669keywords = physical (Clic here for more details about this article) |
8/9. Non-insulin dependent diabetes mellitus in African-American youths of arkansas.Non-insulin dependent diabetes mellitus (NIDDM) occurs more frequently in certain adult populations, including African-Americans. Recently an increase in the incidence of NIDDM has been observed among African-American youths in arkansas. Clinical presentations among these youths vary from asymptomatic to severe diabetic ketoacidosis. From a chart review, data were examined to determine which physical, biochemical, and autoimmune characteristics were most helpful in appropriate classification of NIDDM vs insulin dependent diabetes mellitus (IDDM). It is apparent that several diagnostic and treatment issues need to be addressed to improve the management of African-American youths with NIDDM.- - - - - - - - - - ranking = 0.091147444510669keywords = physical (Clic here for more details about this article) |
9/9. Low bone mineral density in a case of mosaicism klinefelter syndrome: rapid response to testosterone therapy.Male hypogonadism has been recognized as one of the major causes of secondary osteoporosis, but most cases seem to be left undiagnosed. We report a 54-year-old case of mosaicism klinefelter syndrome lacking typical clinical features such as tall stature or low intelligence, who was found to have marked decrease in lumbar bone mineral density (BMD: 0.686 g/cm2) during treatment of diabetes mellitus. In investigation for etiologies of secondary osteoporosis, he was diagnosed as having mosaicism klinefelter syndrome (XXY/XY/XX). Although he was infertile, he lacked typical clinical features of klinefelter syndrome. testosterone replacement was started, which resulted in an increase in BMD up to 0.712 g/cm2 two months after the initiation of therapy. The fact that BMD increased shortly after the initiation of testosterone replacement therapy in the present case supported a beneficial effect of testosterone on BMD, as recently suggested in idiopathic hypogonadotropic hypogonadism. Although the present case was diagnosed as having mosaicism klinefelter syndrome by investigating etiologies for osteoporosis, it may be stressed that male hypogonadism, in general, should be adequately suspected in the presence of infertility and from the findings of physical examination.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |