CONFIRMING DIAGNOSIS Clinical appearance, dietary history, and anthropometry confirm PCM. If the patient doesn’t suffer from fluid retention, weight change over time is the best index of nutritional status.
The following factors support the diagnosis:
❑ height and weight less than 80% of standard for the patient’s age and sex, and below-normal arm circumference and triceps skinfold
❑ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)
❑ urinary creatinine (24-hour) level used to show lean body mass status by relating creatinine excretion to height and ideal body weight, to yield creatinine-height index.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Cholelithiasis and related disorders:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Echography and X-rays detect gallstones. Other tests may include the following:
❑ Abdominal computed tomography scan or ultrasound reflects stones in the gallbladder.
❑ Percutaneous transhepatic cholangiography, done under fluoroscopic control, distinguishes between gallbladder or bile duct disease and cancer of the pancreatic head in patients with jaundice.
❑ Endoscopic retrograde cholangiopancreatography visualizes the biliary tree after insertion of an endoscope down the esophagus into the duodenum, cannulation of the common bile and pancreatic ducts, and injection of contrast medium.
❑ HIDA scan of the gallbladder detects obstruction of the cystic duct.
❑ Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.
An elevated icteric index and total bilirubin, urine bilirubin, and alkaline phosphatase levels support the diagnosis. The white blood cell count is slightly elevated during a cholecystitis attack. Differential diagnosis is essential because gallbladder disease can mimic other diseases (myocardial infarction, angina, pancreatitis, pancreatic head cancer, pneumonia, peptic ulcer, hiatal hernia, esophagitis, and gastritis). Serum amylase levels distinguish gallbladder disease from pancreatitis. With suspected heart disease, serial cardiac enzyme tests and electrocardiography should precede gallbladder and upper GI diagnostic tests.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetes Mellitus:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The initial presentation of DM can vary. Either type may present with the insidious onset of the symptoms associated with hyperglycemia (polyuria, polydipsia, and polyphagia) or with the abrupt onset of an acute complication [diabetic ketoacidosis (in type 1 DM) or nonketotic hyperglycemic-hyperosmolar coma (in type 2 DM)].
A. Type 1 diabetes. Patients with type 1 DM typically present before the age of 18 years. The symptoms heralding the disease emerge gradually as hyperglycemia appears and becomes more frequent and profound. Physiologic stress (e.g., an acute illness or trauma), which increases the requirement for insulin, can unmask the insulinopenia and give the impression that the problem is acute. Enuresis may be a clue for polyuria in a child who was previously toilet-trained. Lethargy, weakness, and weight loss are other common features.
B. Type 2 diabetes. Patients with type 2 DM usually present after the age of 40 years. The diagnosis is often made in an asymptomatic patient as a result of routine blood tests that reveal an elevation of plasma glucose. Other patients may present with the symptoms of hyperglycemia. The patient may have a history of recurrent skin infections or persistent vulvovaginitis. Other common symptoms include altered sensations in the extremities, nocturia, erectile dysfunction, and visual disturbances (Chapters 4.6, 5.1, 10.3, and 10.4). The use of glucocorticoids, β-adrenergic agonists, or thiazides can precipitate the symptoms of type 2 DM.
Physical examination
Patients often present with similar physical findings in both type 1 and type 2 DM, owing to hyperglycemia. In the young child, failure to grow and gain weight can occur with type 1 DM. The child may be ill appearing, lethargic, and often have signs of dehydration (tachypnea, tachycardia, and low blood pressure). Ketone production will produce a fruity odor on the patient’s breath. The patient with type 2 DM tends to be obese (especially upper body obesity) and may appear fatigued and have muscle weakness or decreased vision. The neurologic examination may reveal painful feet and numbness. Monilial infections may be found in the vagina and pubic areas.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Diabetes insipidus:
Diagnosis
(Handbook of Diseases)
Urinalysis reveals almost colorless urine of low osmolality (50 to 200 mOsm/kg, less than that of plasma) and low specific gravity (less than 1.005). However, a diagnosis requires the water deprivation test to provide evidence of vasopressin deficiency, resulting in the kidneys’inability to concentrate urine.
Water deprivation test
In this test, after baseline vital signs, weight, and urine and plasma osmolalities are obtained, the patient is deprived of fluids and observed to make sure he doesn’t drink anything surreptitiously. Hourly measurements then record the total volume of urine output, body weight, urine osmolality or specific gravity, and plasma osmolality. Throughout the test, blood pressure and pulse rate must be monitored for signs of orthostatic hypotension.
Fluid deprivation continues until the patient loses 3% of his body weight (indicating severe dehydration). When urine osmolality stops increasing in three consecutive hourly specimens, the patient receives 5 units of aqueous vasopressin subcutaneously (S.C.).
Hourly measurements of urine volume and specific gravity continue after S.C. injection of aqueous vasopressin. Patients with pituitary diabetes insipidus respond to exogenous vasopressin with decreased urine output and increased specific gravity. Patients with nephrogenic diabetes insipidus show no response to vasopressin.
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Source: Handbook of Diseases, 2003
Diabetes mellitus:
Diagnosis
(Handbook of Diseases)
In nonpregnant adults, diabetes mellitus is diagnosed with:
❑ at least two occasions of a fasting plasma glucose level greater than or equal to 126 mg/dl
❑ typical symptoms of uncontrolled diabetes and a random blood glucose level greater than or equal to 200 mg/dl
❑ a blood glucose level greater than or equal to 200 mg/dl at 2 hours after ingestion of 75 grams of oral dextrose.
Two tests are required for diagnosis; they can be the same two tests or any combination and may be separated by more than 24 hours.
An ophthalmologic examination may show diabetic retinopathy. Other diagnostic and monitoring tests include urinalysis for acetone and blood testing for glycosylated hemoglobin, which reflects glucose control over the past 2 to 3 months.
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Source: Handbook of Diseases, 2003
Diabetic complications during pregnancy:
Diagnosis
(Handbook of Diseases)
The prevalence of gestational diabetes makes careful screening for hyperglycemia appropriate in all pregnancies in each trimester. Abnormal fasting or postprandial blood glucose levels and clinical signs and history suggest diabetes in patients not previously diabetic. A 3-hour glucose tolerance test confirms diabetes mellitus when two or more values are above normal.
Diagnosis of fetal status
Procedures to assess fetal status include stress and nonstress tests, ultrasonography to determine fetal age and growth, measurement of urinary or serum estriols and of phosphatidylglycerol and determination of the lecithin-sphingomyelin ratio from amniotic fluid to predict pulmonary maturity.
Clinical tip Nonstress tests must be done from 30 to 38 weeks’ gestation because the placenta tends to degenerate faster in gestational diabetes.
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Source: Handbook of Diseases, 2003
Protein-calorie malnutrition:
Diagnosis
(Handbook of Diseases)
Clinical features, dietary history, and anthropometry confirm protein-calorie malnutrition. If the patient doesn’t suffer from fluid retention, weight change over time is the best index of nutritional status.
The following factors support the diagnosis:
❑ height and weight less than 80% of standard for the patient’s age and sex, and below-normal arm circumference and triceps skinfold
❑ serum albumin level less than 2.8 g/dl (normal: 3.3 to 4.3 g/dl)
❑ urinary creatinine (24-hour) level is used to show lean body mass status by relating creatinine excretion to height and ideal body weight, to yield creatinine-height index
❑ skin tests with standard antigens to indicate degree of immunocompromise by determining reactivity expressed as a percentage of normal reaction
❑ moderate anemia.
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Source: Handbook of Diseases, 2003
Cholelithiasis, cholecystitis, and related disorders:
Diagnosis
(Handbook of Diseases)
Ultrasonography and X-rays detect gallstones. Specific procedures include the following:
❑ Ultrasonography reflects stones in the gallbladder with 96% accuracy.
❑ Percutaneous transhepatic cholangiography allows imaging under fluoroscopic control to help distinguish between gallbladder or bile duct disease and cancer of the pancreatic head in patients with jaundice.
❑ Endoscopic retrograde cholangiopancreatography visualizes the biliary tree after insertion of an endoscope down the esophagus into the duodenum, cannulation of the common bile and pancreatic ducts, and injection of contrast medium.
❑ Hepatobiliary iminodiacetic acid analogue scan of the gallbladder helps detect obstruction of the cystic duct.
❑ Computed tomography scan, although not routinely used, helps distinguish between obstructive and nonobstructive jaundice.
❑ Plain abdominal X-rays identify calcified but not cholesterol stones with 15% accuracy.
❑ Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.
Elevated icteric index and elevated total bilirubin, urine bilirubin, and alkaline phosphatase levels support the diagnosis. White blood cell count is slightly elevated during a cholecystitis attack.
Differential diagnosis is essential because gallbladder disease can mimic other diseases (myocardial infarction, angina, pancreatitis, pancreatic head cancer, pneumonia, peptic ulcer, hiatal hernia, esophagitis, and gastritis). Serum amylase levels help distinguish gallbladder disease from pancreatitis. With suspected heart disease, cardiac enzyme testsand an electrocardiogram should precede gallbladder and upper GI diagnostic tests.
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Source: Handbook of Diseases, 2003
GLYCOSURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The investigation of glycosuria should include a glucose tolerance
test, chemistry panel, and electrolyte panel. A clinical history of
polyuria, polyphagia, weakness, and weight loss will be helpful. If there
are clinical features of one of the endocrine diseases listed above, various
tests for these disorders and an endocrinology consult should be ordered.
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Source: Differential Diagnosis in Primary Care, 2007
HYPERGLYCEMIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Obviously, the first thing to do is repeat the blood sugar test after
fasting. If the result is borderline, a glucose tolerance test should be
done. Clinical evaluation for a history of diabetes, hypertension (Cushing
disease and pheochromocytoma), protruding jaw and increasing hat size
(acromegaly), polyuria, polydipsia, and weight loss (diabetes mellitus and
hyperthyroidism) is important. Further workup depends on which endocrine
disorder is being considered.
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Source: Differential Diagnosis in Primary Care, 2007
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