Obesity

The line on the gums of this 30-year-old man indicates lead poisoning. The patient had been employed for 8 months at a lead smelting plant in which no occupational safety precautions had been enforced. He was admitted to the hospital with the classic symptoms and signs of lead poisoning--pain in the nape of the neck that radiated down the spine, posterior thighs, and calves to the plantar aspect of the feet; colicky panabdominal pain; anorexia; weight loss; nausea; vomiting; constipation; bone and muscle tenderness; hyperesthesia of all extremities; insomnia; irritability; generalized weakness; malaise; and dizziness.

Have any specific genes been identified for type 1 or type 2 diabetes? If so, howmany genes are involved?

The authors of the Women’s HealthInitiative (WHI) study involving50,000 postmenopausal women concluded thata low-fat diet (goal: 20% of total calories) had no significant effect on the incidence of breast cancer, coloncancer, or heart disease. What should we be telling our patients?

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.

Q:What is the best screening test for suspectedrenal artery stenosis?

A 66-year-old man presented with weight loss for 2 months, loss of appetite for several weeks, and abnormal chest radiographic findings. He denied chest pain, cough, fever, chills, shortness of breath, and chest trauma. He was an active smoker, with a 50-pack-year history of smok- ing, and a cocaine and alcohol abuser. His history included treatment of hypertension for 10 years and treatment of pulmonary tuberculosis 14 years previously.

Abstract: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common, yet often overlooked, form of symptomatic sleep-disordered breathing. OSAHS is a cause for concern for several reasons, one of which is its association with cardiovascular disease. Risk factors include obesity, hypertension, and upper airway malformations. Diagnostic clues include habitual snoring, witnessed apneas, choking arousals, excessive daytime sleepiness, and large neck circumference. Polysomnography is the definitive diagnostic test; it pro- vides objective documentation of apnea and hypopnea. Since OSAHS may contribute to adverse postsurgical events, consideration of this syndrome should be part of the preoperative assessment of patients. (J Respir Dis. 2006;27(4):144-152)

Abstract: Multidrug-resistant tuberculosis is defined as tuberculosis caused by strains that have documented in vitro resistance to isoniazid and rifampin. Treatment involves a regimen consisting of at least 4 or 5 drugs to which the infecting strain has documented susceptibility. These agents may include ethambutol, pyrazinamide, streptomycin, a fluoroquinolone, ethionamide, prothionamide, cycloserine, and para-aminosalicylic acid. In addition, an injectable agent, such as kanamycin, amikacin, or capreomycin, should be used until negative sputum cultures have been documented for at least 6 months. If the patient has severe parenchymal damage, high-grade resistance, or clinically advanced disease, also consider clofazimine, amoxicillin/clavulanate, or clarithromycin, although there is little evidence supporting their efficacy in this setting. Routine monitoring includes monthly sputum smear and culture testing, monthly assessment of renal function and electrolyte levels, and liver function tests every 3 to 6 months. (J Respir Dis. 2006;27(4):172-182)

In this article, I review several interventions that have been shown or are postulated to reduce breast cancer risk in women with no history of the disease; these include chemoprevention, physical activity, weight control, diet, alcohol use, and avoidance of specific carcinogens.

Rheumatoid arthritis (RA) affects 1% ofadults during their most productiveyears and can result in significant disability.The goals of therapy are to reducepain, limit joint destruction, andpreserve function.

A 54-year-old woman presents with severe, throbbingpain in her right shoulder that began 3 daysearlier. She has no history of trauma or of problems withthis shoulder. She denies shortness of breath, fever,chills, and rash.

A 35-year-old woman has been losing weight and has hadworsening abdominal pain and fullness for the past 2 months.She denies nausea, vomiting, and fever. Medical history issignificant only for asthma.

You routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.

Chronic headache that worsened when she bent forward and episodes of usually unilateral vision loss sent a 34-year-old woman for medical consultation. The vision loss occasionally occurred in both eyes simultaneously.

Excess weight increases the risk of having a heart attack, stroke, high blood pressure, arthritis, diabetes, depression, fatigue, and certain types of cancer. Losing weight and keeping it off are very difficult for most persons who are overweight. Here are some suggestions to help you lose pounds and keep your weight down.

In this article, we review the factors that contribute to obesity. We then describe effective approaches to weight control, including exercise, dietary modification, drug treatment, and bariatric surgery.

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

Weight gain is a well-known risk factor for the development of sleep-disordered breathing (SDB), and there is some evidence that weight loss can lead to improvement in SDB. Data from the Sleep Heart Health Study indicate that even modest changes in weight can be significant, especially in men.

For 3 years, a 23-year-old man has had this asymptomatic, 0.75-cm, polypoid lesion on his left wrist.

Every day, patients are bombarded with conflicting information about what constitutes a healthful diet. By focusing on patients' needs, risk factors, lifestyle, and eating habits, you can help them make the right choices.

A 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.

ABSTRACT: To provide effective dietary counseling, offer practical strategies that mesh with patients' lifestyles. Emphasize what to add to or include in the diet rather than what to avoid or cut back on, and aim for progress and small changes rather than a complete makeover. Recommend that patients "colorize" their diet (ie, include more colorful fruits and vegetables). Those who need to lose weight should keep a food log of all they eat and drink and use the "plate method" to control portion sizes.

An 85-year-old man with a history of hypertension, coronary artery disease, and diabetes mellitus presented with syncope. He had fallen down a flight of stairs and now complained of left shoulder pain

Abstract: Shortness of breath is a common complaint associated with a number of conditions. Although the results of the history and physical examination, chest radiography, and spirometry frequently identify the diagnosis, dyspnea that remains unexplained after the initial evaluation can be problematic. A stepwise approach that focuses further testing on the most likely diagnoses is most effective in younger patients. Early bronchoprovocation challenge testing is warranted in younger patients because of the high prevalence of asthma in this population. Older patients require more complete evaluation because of their increased risk of multiple cardiopulmonary abnormalities. For patients who have multiple contributing factors or no clear diagnosis, cardiopulmonary exercise testing can help prioritize treatment and focus further evaluation. (J Respir Dis. 2006;27(1):10-24)

16-month-old previously healthy child is hospitalized after 36 hours of worsening painful edema and erythema of the right lower leg and high fever with chills.

A 76-year-old man presents with a sudden severe, painless loss of vision in his left eye.

A 45-year-old man was referred to our pulmonary clinic for progressive dyspnea and worsening asthma. His shortness of breath had been worsening over the past 2 years. He denied fever, weight loss, and other systemic complaints.

Abstract: The manifestations of indoor mold-related disease (IMRD) include irritant effects, such as conjunctivitis and rhinitis; nonspecific respiratory complaints, such as cough and wheeze; hypersensitivity pneumonitis; allergic fungal sinusitis; and mycotoxicosis. The diagnosis of IMRD depends on eliciting an accurate history and excluding preexisting pathology that would account for the patient's symptoms. Laboratory tests, imaging studies, and spirometry can play an important role in ruling out other diagnoses, such as allergic or nonallergic rhinitis, asthma, and pneumonia. The diagnosis of IMRD also involves integrating the results of immunologic, physiologic, and imaging studies with the results of indoor air-quality studies. (J Respir Dis. 2005;26(12):520-525)

Under what circumstances is endoscopy advisable for a patient with dyspepsia?

A 49-year-old man has had dyspnea on exertion for 1 month; it has worsened during the past 2 days. He has also had 2 episodes of epistaxis and increasing abdominal distention, without pain, during the past 6 months.