Print Issue: October 09, 2007

INHALED INSULIN WITH ALZHEIMER’S?

What is the effect of using inhaled insulin to address insulin resistance in patients with Alzheimer’s disease?—Catherine Godek, ARNP-C, Tiverton, R.I. While insulin does address elevated plasma glucose levels that can result from insulin resistance, there is no specific reason that inhaled insulin is superior to injected insulin. You do not mention how you know…

UNREQUESTED GFR DETERMINATIONS

Our local laboratories have been adding glomerular filtration rates (GFR) to our basic metabolic panels. What should we do when the GFR indicates stage 3 chronic kidney disease but the creatinine level is normal?—Randy Zeid, DO, Browns Mills, N.J. In the absence of a 24-hour urine collection to calculate creatinine clearance, I’ll presume that the…

HYPOTHYROID SYMPTOMS, NORMAL LABS

How should I treat a patient who has signs and symptoms of hypothyroidism but normal lab values? The 36-year-old woman has mitral valve prolapse, menorrhagia, headache, fatigue, brittle nails, hair loss, central weight gain, and cold intolerance but no slowing of responses or decreased deep tendon reflexes.—Jerry Shaw, PA, Memphis Your patient’s symptoms are nonspecific,…

EXERCISE IN FIBROMUSCULAR DYSPLASIA

Can a patient with fibromuscular dysplasia (FMD), which causes thickening and ballooning of large arteries, continue to do exercise with stretching? My patient has significant involvement of the carotid and renal arteries. She would like to continue her exercise program of Pilates and muscle strengthening, but I have been unable to find any information in…

PINPOINTING THE CAUSE OF UNEXPLAINED VASCULAR EPISODES

A 56-year-old woman has had hypertension for 22 years and hypothyroidism and congestive heart failure (CHF) for five years. Recently, she came to the clinic complaining of recurring episodes of flushing and a shooting sensation that travels from her head to her feet and is accompanied by an acute rise in BP. The initial episode…

IS A “VENOUS LEAK” BEHIND ED IN THIS YOUNG PATIENT?

Recently, a college student underwent urologic evaluation for erectile dysfunction (ED), and the urologist suggested that a “venous leak” might be causing the problem. Can you clarify? — Thomas McGrath, MD, Storrs, Conn. The physiology of erection is well-described in the eighth edition of Campbell’s Urology (Walsh PC, Retik AB, eds. Philadelphia, Pa.: WB Saunders;…

FASTING HYPOGLYCEMIA WITH ELEVATED HbA1c

Two patients who were put on Lantus insulin after oral hypoglycemic agents were not sufficiently effective have reported fasting blood sugars in the 60-80 mg/dL range and postprandial blood sugars in the 150-180 mg/dL range. However, at three months, their hemoglobin A1c (HbA1c) is higher than goal, i.e., >7.5%-8.0%. Raising the insulin dose causes morning…

PERIMENOPAUSAL MIGRAINE PROPHYLAXIS

How well does standard migraine prophylaxis work in perimenopausal women averse to hormone therapy?—Paula Y. Carruthers, MD, Sherman Oaks, Calif. This is problematic because doses of preventives sufficient to forestall significant headache disability during menstruation are often not perceived as useful in patients with minimal headaches at other times during the month. My approach to…

Electrical stimulation for easing pain?

Does neuromodulator electrical stimulation work for peripheral pain relief? What is the mechanism of action?—Jorge Guzman Ortiz, MD, Jayuya, P.R. Transcutaneous electrical nerve stimulation (TENS) therapy has been commonly employed in the treatment of peripheral pain, but its mechanism of action is unknown and its efficacy is questionable. One proposed mechanism of action is that…

TREATMENT FOR DIARRHEA BURNS

I have a patient with stage 3 ulcers on the coccyx and diarrhea burns covering her perineal area, vaginal area, inner thighs, and buttocks. Should therapy be the same as that for a regular burn patient?—Bonnie Shipferling, PhD(c), MSN, RN, Friendswood, Tex. A stage 3 pressure ulcer has full-thickness skin loss involving damage to or…

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