contemporary internal medicine
TRANSCRIPT
CONTEMPORARY INTERNAL MEDICINE
Clinical Case Studies
Volume 1
A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publioher.
CONTEMPORARY INTERNAL MEDICINE
Clinical Case Studies
A collection of cases from The Ohio State University Hospitals discussed by faculty of the Department of Internal Medicine
Volume 1
Edited by
Juan Bowen, M.D., and Ernest L. Mazzaferri, M.D. The Ohio State University
Columbw, Ohio
PLENUM MEDICAL BOOK COMPANY NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data
Contemporary internal medicine.
Includes bibliographies and index. 1. Internal medicine-Case studies. I. Bowen, Juan. II. Mazzaferri, Ernest 1.,
1936- . [DNLM: 1. Internal Medicine-case studies. WB 115 C761] RC66.C66 1988 616'.09 88-22379
ISBN-13: 978-1-4615-6715-8
001: 10.1007/978-1-4615-6713-4
e-ISBN-13: 978-1-4615-6713-4
© 1988 Plenum Publishing Corporation
Softcover reprint of the hardcover 15t edition 1988
233 Spring Street, New York, N.Y. 10013
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfIlming,
recording, or otherwise, without written permission from the Publisher
This volume is dedicated to the past physicians of The Ohio State University Department of Internal Medicine, our role models, who at the turn of the century fIrst established the tradition of excellence in
clinical medicine at our institution, and to our students and future colleagues for their perceptive questions, criticism, and stimulation
Starling-Loving Hall By Robert L. Hummel
Contributors
STANLEY P. BALCERZAK, MD, FACP, Director of Hematology and Oncology, Professor of Medicine, The Ohio State University, Columbus, Ohio
PHILLIP F. BINKLEY, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
JUAN BOWEN, MD, Director of General Medicine, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
JAMES H. CALDWELL, MD, FACP, Professor of Medicine, The Ohio State University, Columbus, Ohio
EDWARD A. COPELAN, MD, Asistant Director, Bone Marrow Transplantation Unit, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
FERNANDO G. COSIO, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
MARY E. FONTANA, MD, Associate Professor of Medicine, The Ohio State University, Columbus, Ohio
JACK M. GEORGE, MD, Director of Endocrinolo~ and Metabolism, Professor of Medicine, The Ohio State University, Columbus, Ohio
N. PAUL HUDSON, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
SETH M. KANTOR, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
ROBERT KIRKPATRICK, MD, Director, Liver Service, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
CALVIN M. KUNIN, MD, FACP, Frank E. and Mary W. Pomerene Professor of Infectious Diseases, Professor of Medicine, The Ohio State University, Columbus, Ohio
JANET M. LEIBY, MD, Director, Ambulatory Oncology Unit, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
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viii Contributors
RAYMOND D. MAGORIEN, MD, Associate Professor of Medicine, The Ohio State University, Columbus, Ohio
WILLIAM E. MAHER, MD, Hospital Epidemiologist, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
ERNEST L. MAZZAFERRI, MD, FACP, Chairman, Department of Internal Medicine, Professor of Medicine and Physiology, The Ohio State University, Columbus, Ohio
DONALD L. McNEIL, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
EARL N. METZ, MD, FACP, Vice Chairman, Department of Internal Medicine, Charles A. Doan Professor of Medicine, The Ohio State University, Columbus, Ohio
STEVEN D. NELSON, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
ERIC R. PACHT, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
JOSEPH F. PLOUFFE, MD, FACP, Associate Professor of Medicine, Associate Professor of Medical Microbiology, The Ohio State University, Columbus, Ohio
JAMES M. RYAN, MD, Director, Nuclear Cardiology, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
FRED B. THOMAS, MD, FACP, Director, Gastroenterology Training Program, Professor of Medicine, The Ohio State University, Columbus, Ohio
PIERRE L. TRIOZZI, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
DOUGLAS B. VAN FOSSEN, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
MARK D. WEWERS, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio
Preface
Read with two objectives: first, to acquaint yourself with the current knowledge of a subject and the steps by which it has been reached; and secondly, and more important, read to understand and analyze your cases.
William Osler, The Student Life
What follows is a collection of cases-or more aptly, the stories of our patients and friends who have been seen at The Ohio State University Hospitals where our faculty have provided their care and about whom this volume is written. Today many fear that our patients are being moved from center stage while we are being distracted by the technology of medicine.This volume was written with patients in mind. The idea is that the most intriguing questions and the most rewarding answers begin and end at the bedside. This is a story of our patients, told by expert clinicians and spiced with commentary along the way. This volume in no way attempts to be comprehensive. Instead, it is like the practice of medicine, scattered, somewhat disjointed, while at the same time intensely personal and focused upon whatever problem the patient brings to us. The discussions are not so much about disease entities as they are about patients with problem". The two are uniquely different. For instance, when the physician suspects hepatitis, not every imaginable cause can be actively investigated. Instead, tests and procedures are discriminately chosen, a part of medicine that is still more art than science. The cases presented in this book are discussed in a format that shows the art of medicine in a framework of science. In all, 25 cases, both the common and the unusual, are presented. Each is summarized with the author's comments, which emphasize the important historical features and salient physical diagnostic points. This is followed by a discussion of the contemporary issues, including pathophysiology, diagnosis, treatment, and prognosis, as they related to the patient's case. References selected are those which the author considers the best or most important recent citations on the subject. This is the first of a series of volumes that will present our most interesting and challenging patients in a case study format. We hope the practicing clinician will fmd this book useful.
Juan Bowen, MD Ernest L. Mazzaferr~ MD, FACP
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Acknowledgment
The editors wish to thank Dr. Earl N. Metz for his editorial assistance in the preparation of this book. His wisdom, thoughtfulness and careful reading of the manuscript are deeply appreciated. The authors also wish to thank Luanne Frey and Teresa Moynihan for their expert secretarial assistance.
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Contents
Case 1 Chronic Liver Disease and Neurologic Abnormalities .................. 1 FredB.Thomas, MD, FACP
In this case study of Wilson's disease, the author discusses contemporary views of its pathophysiology and clinical features, along with the differential diagnosis of chronic liver disease.
Case 2 Dyspnea and Rapidly Enlarging Goiter ......................................... 18 Ernest L. Mazza/erri, MD, FACP
A patient with Hashimoto's thyroiditis and thyroid lymphoma provides the framework for a discussion of these increasingly more common disorders. The author includes a summary of the clinical approach to nodular goiter.
Case 3 Atheroembolic Disease Mimicking Systemic Vasculitis ............... 33 Fernando G. Cosio, MD
This case highlights the clinical and laboratory features of atheromatous embolic disease of the kidneys, emphasizing laboratory features of the disease which may lead to diagnostic confusion.
Case 4 E~hrocytosis ••••....•.•..••.•..•••••..••..•••..••..•....•..••..•.••.....•....••.................. 45 Stanley P. Balcerzak, MD, FA CP
A patient with polycythemia furnishes the setting for a discussion of the pathophysiology, differential diagnosis, and treatment of a classic problem in internal medicine.
Case S Obstructive Sleep Apnea ................................................................... S9 Eric R.Pacht, MD
A patient with snoring, nightmares, and palpitations during sleep provides the basis for a discussion of the current concepts
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Case 6
in the diagnosis and treatment of obstructive sleep apnea, an important but frequently misdiagnosed condition.
Contents
Dyspnea and Cirrhosis ........... __ •••••••••••••••••••••••••••••••••••••••••••••••••••••••• 70 Mark D. Wewen, MD
A case of alpha-I-antitrypsin deficiency is reviewed by an author who has done pioneering work in this area. The inheritance, pathophysiology, and clinical features of the disorder are discussed in detail.
Case 7 Chest Pain in a Young Man ............................................................... 82 James M. Ryan, MD
This case study of a young patient with coronary artery disease emphasizes the logical evaluation of this common problem. The author analyzes testing strategies based on current concepts of medical decision-making.
Case 8 A Reactive Arthropathy ••••••••••••••••••.••.••.•••••••••••••••••••••••••••••.•••••••••.•••• 95
Case 9
N. Paul Hudson, MD
A patient with low back pain and joint complaints sets the stage for a discussion of the distinctive features, diagnosis, and treatment of the sero-negative spondyloarthropathies.
Community Acquired Pneumonia • __ •..••••••••••••••••.•••.••..•••....••••...••••• 104 Joseph F. Plouffe, MD, FACP
In this case study of a patient with pneumonia, the author reviews the current diagnostic and treatment decisions involved in this common and difficult clinical problem.
Case 10 Lens Subluxation and Tall Stature ••••••••••••••••••••••••••••••••••••••••••••••••• 116 Juan Bowen, MD
A patient with Marfan syndrome is the motivation for a discussion of the clinical features, diagnosis, and pathophysiology of this important disorder.
Contents xiii
Case 11 Breast Cancer in a Premenopausal Woman .................................. 128 Jane M. Leiby, MD and Earl N. Metz, MD, FACP
This case study highlights the major contemporary clinical issues surrounding this tragic problem which is among the most difficult dilemmas facing the practicing physician.
Case 12 Recurrent Fever, Chills, Pyuria, and Bacteriuria in an Adult Male Following Urinary Catheterization ........................................ 140
Calvin M. Kunin, MD, FACP
A case study of chronic prostatitis leads to a discussion of the causes, contemporary diagnostic approaches, and treatment of recurrent urinary tract infections.
Case 13 Fever and Bloody Diarrhea .••................................•.....••..•................. 148 William E. Maher, MD
A patient with infectious bloody diarrhea is presented with emphasis on the essential epidemiologic and clinical features. Recently recognized pathogens such as Campylobacter jejuni are discussed.
Case 14 Chest Pain and Heart Murmur in a Young Woman ..................... 159 Mary E. Fontana, MD
This is a case of mitral valve prolapse, the most common heritable disorder of connective tissue with cardiovascular manifestations. The author discusses the causes, cardiac dynamics, diagnosis, and complications of mitral valve prolapse.
Case 15 Peptic Ulcer Disease .......................................................................... 176 James H. Caldwell, MD, FACP
A patient with peptic ulcer disease provides the backdrop for a discussion of recent developments in the etiology, pathophysiology, diagnosis, and treatment of this common problem.
xiv Contents
Case 16 Microcytic Anemia ............................................................................. 191 Pierre L. Triozzi, MD
A case of thalassemia provides the framework for a discussion of the distinctions between iron deficiency anemia, hemoglobinopathies, and other reasons for microcytosis.
Case 17 Recurrent Abdominal Pain and Edema ......................................... 202 Donald L. McNeil, MD
In this case of hereditary angioedema, the crucial clinical distinction between this life-threatening disease and other urticarial disorders is discussed.
Case 18 Hepatitis in a Chinese Student ....................................................... .216 Roberl Kirkpatrick, MD
This discussion focuses on the clinical evaluation of chronic hepatitis, with emphasis on the appropriate interpretation of serological tests for hepatitis.
Case 19 A Woman with Rheumatoid Arthritis .............................................. 227 Seth M. Kantor, MD
The author reviews pertinent clinical issues in the diagnosis and treatment of rheumatoid arthritis.
Case 20 Aortic Stenosis .................................................................................... 240 Doug/as B. Van Fossen, MD
The clinical features, natural history, and current therapy of obstructive aortic valvular disorders are discussed in the context of a patient with aortic stenosis.
Case 21 A Case of Weakness and Fatigue in a Teenager •••.•.....•••..•••..•••••••.. 259 Jack M. George, MD
A patient with Addison's disease provides the circumstances for a clinical discussion of acute and chronic adrenal insufficiency.
Contents xv
Case 22 Practical Approach to Syncope ........................................................ 266 Steven D. Nelson, MD
A common and potentially serious clinical problem is discussed from the vantage point of the electrophysiologic derangements that may cause syncope.
Case 23 Tbrombocyto:penia ............................................................................. 280 EdwardA. Copelan, MD
A patient with idiopathic thrombocytopenia gives insight into our contemporary understanding of the pathophysiology, diagnosis, and treatment of the immune thrombocytopenias.
Case 24 New Onset of Dyspnea in a Middle-Aged Man .............................. 290 Phillip F. Binkley, MD
A patient with dilated cardiomyopathy provides the basis for a discussion ofthis disorder. The author summarizes innovative diagnostic and therapeutic approaches which have been developed in the past decade.
Case 2S Test Case ............................................................... _ ............................ 301 Raymond D. Magorien, MD
A patient with acute myocardial infarction forms the framework for an approach to the contemporary management of this disorder. The author provides a step-by-step guide to management in a question-and-answer format.
Index ... _ .................................................................................................................. 313