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May stimulate surrounding tissue to secrete androgens
Krukenberg’s tumors of the ovary stimulate surrounding ovarian stromal tissue to produce excess androgen. When onset of hair growth (with or without frank virilization) is very rapid, a neoplastic source of androgen is suggested. As well as ovarian tumors, the potential neoplasms include adenomas and carcinomas of the adrenal gland.
Often associated with elevated 17-hydroxyprogesterone levels
Attenuated forms of adrenal hyperplasia can present with hirsutism at puberty or in adulthood. Elevated levels of a precursor of cortisol biosynthesis such as 17-hydroxyprogesterone, 17-hydroxypregnenolone, or 11-deoxycortisol can present. ACTH infusion will increase the precursor level, and dexamethasone will suppress it.
A 15-year-old girl has been losing weight and exercising vigorously. She feels overweight and wants to lose more weight. On examination, she is thin with muscle wasting. Which of the following physical signs is also suggestive of the diagnosis?
Salivary gland enlargement occurs both in anorexia nervosa (AN) and bulimia (BN). Other common findings in AN include constipation, bradycardia, hypotension, hypercarotinemia, and soft downy hair growth (lanugo). Menses are usually absent.
A 17-year-old man is brought to the emergency room because of weakness and weight loss. He is diagnosed with an eating disorder and admitted to the hospital. Which of the following lab values is not consistent with this diagnosis?
Hyperglycemia is not seen in eating disorders, and would suggest an alternate diagnosis for the weight loss such as diabetes. Hypoglycemia and low estrogens and gonadotropins are frequently seen in anorexia nervosa (AN). BUN and creatinine may be elevated. Hypochloremia, hypokalemia, and alkalosis are frequently seen in BN.
A 22-year-old woman is brought to hospital because of syncope. There were no warning symptoms, and she was fine after the event. Recently she has lost 40 lb because of an eating disorder. She weighs 70 lb, looks unwell, and has little muscle bulk. The blood pressure is 80/60 mm Hg and pulse 50/min. Which of thefollowing is the most likely abnormality on her ECG?
Low QRS voltages, sinus bradycardia, and ST-T changes are common. However, the presence of a prolonged QT interval is most suggestive of serious cardiac arrhythmias.
Which of the following indications for hospitalization is the most appropriate for patients with eating disorders?
Hospitalization should be considered when the body weight dips below 75% of the expected. The goal is to achieve a weight of 90% of that expected. Vomiting is more characteristic of bulimia than anorexia nervosa (AN).
Which of the following is the most likely explanation for the dental abnormalities in bulimia nervosa (BN)?
Recurrent vomiting and exposure of the teeth to stomach acid leads to loss of dental enamel and eventual chipping and erosion of the teeth. The vomiting may be manually induced, but eventually most patients with bulimia (BN) are able to trigger vomiting at will.
A 64-year woman with Type II diabetes for 10 years now develops increasing fatigue, dyspnea, and pedal edema. On examination, her blood pressure is 165/90 mm Hg, pulse 90/min, JVP is 4 cm, heart sounds are normal, lungs are clear, and there is 3+ pedal edema. Her urinalysis is positive for 3 gm/L of protein and no casts. Which of the following renal diseases is the most likely diagnosis in this patient?
The patient is most likely to develop glomerulosclerosis. This can be diffuse or nodular (Kimmelstiel-Wilson nodules). Poor metabolic control is probably a major factor in the progression of diabetic nephropathy.
Which of the following statements concerning the prognosis of anorexia nervosa (AN) and bulimia nervosa (BN) is correct?
AN has one of the highest mortality rates of any psychiatric illness at 5% per decade. The mortality for BN is very low, and 50% have a full recovery within 10 years. Only 25% have persistent symptoms of BN over many years, and the disease does not usually progress to AN.
A 24-year-old female is placed on a low residue and low fiber diet. She has a long history of right lower quadrant pain, cramps, and diarrhea.
Low fiber diets are frequently prescribed during flares of inflammatory bowel disease to reduce diarrhea and pain. There is no level 1 evidence to support this practice. Similar diets are often prescribed for diverticulitis or other conditions associated with a narrowed or stenosed colon. It may be prescribed for patients with a new ostomy. When acute symptoms subside, however, restrictions concerning dietary fiber should be stopped.
A 56-year-old man is started on a low caloric and weight loss diet. He recently started feeling unwell, had vision changes, and noticed numbness in his feet.
Restricting caloric intake and weight reduction are important components of the medical nutrition therapy for patients with diabetes. Most patients should be referred to a dietician to help construct a diet appropriate in caloric intake.
A 52-year-old woman is started on a low sodium diet. She feels well and is experiencing no symptoms. Her physical examination is normal except for a sustained cardiac apical impulse.
Some patients with hypertension are salt sensitive, and will lower their blood pressure with salt restriction. Low sodium diets are also recommended in patients with congestive heart failure (CHF), ascites, or chronic renal failure.
A 64-year-old man is placed on a low simple sugar diet. He is experiencing symptoms of crampy abdominal discomfort, nausea, diarrhea, and diaphoresis 15–30 minutes after eating.
After gastrectomy, avoiding simple sugars and limiting liquids can ameliorate symptoms of dumping. Early dumping occurs within 30 minutes of eating and is characterized by vasomotor symptoms such as palpitations, tachycardia, lightheadedness, and diaphoresis. Late dumping includes similar symptoms plus dizziness, confusion, and even syncope. It occurs 1.2–3 hours after eating.
A 45-year-old woman is placed on a protein restriction diet and a daily laxative regimen. She recently had a hospital admission for confusion related to a chronic illness.
The symptoms of hepatic encephalopathy are improved with protein restriction and a bowel elimination routine with lactulose. It is presumed that this results in lower levels of serum ammonia, but other substances in the serum may be implicated. These include mercaptans, short-chain fatty acids, and phenol. Gamma-aminobutyric acid (GABA) levels in the brain are also increased. Chronic encephalopathy can be controlled with restricting protein intake and taking lactulose (osmotic laxative). Restricting daytime protein intake in patients with Parkinson’s disease may improve the efficacy of levodopa therapy.
A 38-year-old woman is told to limit chocolate and caffeine intake for worsening symptoms. She is also told that weight loss is helpful in improving the symptoms for her condition.
Chocolate, ethanol, caffeine, and tobacco decrease lower esophageal sphincter pressure. Other effective treatments for GERD include low fat diet, weight loss, avoiding bedtime snacks, and elevating the head of the bed while sleeping
An 83-year-old man with poor nutrition notices easy bruising and bleeding gums. On examination, he has inflamed bleeding gums, multiple areas of ecchymoses, and perifollicular hemorrhages. His coagulation profile and liver function is normal.
Scurvy is characterized by a tendency to hemorrhage and perifollicular hyperkeratotic papules in which hairs become fragmented and buried. Gums are involved only if teeth are present. It can occur in infants 6–12 months of age who are on processed milk formulas, without citrus fruit or vegetable supplementation. The peak incidence in the United States is in poor and elderly people and alcoholics. It is frequently associated with other nutritional deficiencies (e.g., folic acid)
A 26-year-old woman started developing frequent headaches, dizziness, and double vision after starting a “megavitamin” program. Her examination is normal except for papilledema.
Excessive vitamin A ingestion can cause abdominal pain, nausea, vomiting, headache, dizziness, and papilledema. Deficiency of vitamin A can cause night blindness and progress to visual loss. It is common in children in developing countries and is a major cause of blindness.
A 57-year-old man has dyslipidemia with a low HDL and high triglyceride pattern. Recently the dose of one of his medications was increasedand he started experiencing flushing and pruritus secondary to histamine release.
Pharmacologic doses of niacin for hypercholesterolemia may cause histamine release, which results in flushing, pruritus, and GI disturbance. Asthma may be aggravated, acanthosis nigricans can occur, and in high doses, elevation of uric acid and fasting blood sugar can occur. Hepatic toxicity, including cholestatic jaundice, has been described with large doses.
A 43-year-old woman with chronic alcoholism presents with shortness of breath and edema. On examination, her blood pressure is 100/60 mm Hg, pulse 110/min, JVP is 8 cm, the cardiac apex is displaced and enlarged, there are bilateral inspiratory crackles, and there is pedal edema.
Thiamine deficiency can cause high-output cardiac failure (wet beriberi) or neurologic symptoms (dry beriberi). In North America, thiamine deficiency occurs in alcoholics or those with chronic disease. In alcoholics, deficiency is secondary to low intake, impaired absorption and storage, and accelerated destruction. Genetic factors are important as clinical manifestationsoccur only in a small proportion of chronically malnourished individuals. Beriberi heart disease is characterized by peripheral vasodilatation, sodium and water retention, and high-output CHF.
A 52-year-old alcoholic notices a skin rash on his chest, and also has symptoms of diarrhea and abdominal pain. On examination, he has a scaly and pigmented rash on the sun-exposed areas of his skin, the abdomen is soft, and his short-term memory is impaired. He has dermatitis, diarrhea, and dementia syndrome.
Diarrhea, dementia, and dermatitis are the classic triad for pellagra (niacin deficiency). The diagnosis is based on clinical suspicion and response to therapy, and can be confirmed by demonstrating low levels of the urinary metabolites 2-methylnicotinamide and 2-pyridone. Small doses of niacin (10 mg/day) with adequate dietary tryptophan will cure pellagra secondary to nutritional deficiency.
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