Clinical vignette: A 76-year-old man consults you for increasing shortness of breath over the past two years and an increasing requirement for home oxygen. A video-assisted thoracoscopic lung biopsy shows findings of usual interstitial pneumonitis, and he has no identifiable cause for pulmonary fibrosis, so he is considered to have idiopathic pulmonary fibrosis (IPF). His diffusing capacity for carbon monoxide (DLCO) is 45% of predicted, and his total lung capacity is 40% of predicted. Because of his advanced age, he is not considered a candidate for lung transplantation. What treatment should you recommend?
A 38-year-old man with a history of HIV infection virologically suppressed on antiretroviral therapy presents to his gastroenterologist for evaluation of iron deficiency anemia and weight loss. A diagnostic colonoscopy demonstrates a two-centimeter ulcerated mass in the cecum. Biopsies of the lesion return moderately differentiated adenocarcinoma that is wild type for the KRAS mutation by real-time PCR.
Martin J. Wolff, Michael A. Poles, Judith A. Aberg
Clinical vignette: A 48-year-old man with chronic kidney disease stage five due to type II diabetes mellitus and hypertension was referred for hemodialysis initiation. His physical exam showed a blood pressure of 150/80, normal fundi, a positive fourth heart sound (S4), and trace pedal edema. Moderate aortic calcification was present on prior chest X-ray. The ECG showed left ventricle hypertrophy by voltage and slight prolongation of the QT interval. Medications included chlorthalidone, amlodipine, carvedilol, cholecalciferol, erythropoietin, and a phosphate binder. What additional therapy should be initiated to reduce vascular calcifications and cardiovascular mortality?
L. Darryl Quarles
Clinical vignette: A 38-year-old man consults you in the GI clinic because of frequent episodes of epigastric pain, nausea, and tiredness. His blood count shows signs of mild iron deficiency anemia. Upper GI endoscopy was normal, but antral and corpus biopsy specimens show evidence of gastric atrophy and
Emad M. El-Omar
Clinical vignette: A 29-year-old woman is referred for management of infertility. After menarche at age 12, menses occurred irregularly for a year and then became regular. She initiated use of oral contraceptive pills at the age of 18, then stopped at age 27 to try to conceive. Evaluation revealed hyperprolactinemia with serum prolactin of 90 ng/ml; pituitary MRI showed a 6-mm microadenoma. Other pituitary function tested was normal. Therapy was initiated with bromocriptine, but it was poorly tolerated, with fatigue, nausea, and lightheadedness to the point of syncopal events during her work as a hairdresser. Treatment was changed to cabergoline, with similar difficulties. Prolactin levels declined to the 30s–40s, but she was never able to tolerate the medication sufficiently to attain normal prolactin levels, and menses were sporadic and infrequent, with only 2–3 occurring per year. She and her husband had not conceived despite regular unprotected intercourse. She asks whether other medical treatment options might be available for her infertility.
Ursula B. Kaiser
Clinical vignette: A 68-year-old woman consults you after a recent bone mineral density screening revealed osteopenia, total hip T score of –1.8. Further evaluation shows her only other abnormal lab value is a serum 25-hydroxyvitamin D [25(OH)D] level of 13 ng/ml (normal 30–80). You find no evidence of malabsorption. What vitamin D supplement regimen should you recommend to reduce her risk of fractures?
Cathleen S. Colón-Emeric, Kenneth W. Lyles
Clinical vignette: A 59-year-old aeronautical engineer is referred to you for evaluation because of increasing difficulty with job performance over the last several years. Difficulty managing home finances, getting lost driving, and forgetting appointments have become common. Previously outgoing, he is now depressed and irritable. After appropriate neurologic assessment, including brain imaging and metabolic studies, you make the diagnosis of Alzheimer’s dementia and are asked by the patient’s family what treatment is available.
Warren J. Strittmatter
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