M. Hamil. Kentucky State University.
Suggested Answer: According to the Christopher study order doxycycline with mastercard antimicrobial kitchen towel, patients with a suspected diagnosis of pulmonary embolism and a modifed Wells score ≤4 should receive D-dimer testing to evaluate for pulmonary embolism order generic doxycycline on-line antibiotic linezolid. T e patient in this vignete is complicated: although he presents with the sudden onset of dyspnea, an alternative diagnosis— congestive heart failure— may be a more likely cause of his symptoms. If you believe that this patient is most likely experiencing a congestive heart failure exacerbation, it would probably not be appropriate to evaluate him for a pulmonary embo- lism at all, because only patients with clinically suspected acute pulmonary embolism were included in the Christopher study. T us, although the Christopher study provides a helpful protocol for eval- uating patients with a suspected pulmonary embolism, clinical judgment re- mains critical for ensuring that the protocol is used appropriately. Efectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. How Many Patients: 1,147 Study Overview: Randomized controlled investigator-blinded noninferiority clinical trial, with V/Q scan representing the standard of care. Interventions: All patients underwent a clinical pretest probability assign- ment by a physician using the Wells model, along with a D-dimer assay. T e vast majority (89%) of patients were outpatients; thus results cannot be gener- alized to inpatient populations. She has recently had a diagnosis of breast cancer for which she had a modifed radical mastectomy within the last month and is undergoing systemic therapy. She has tachycardia on physical examination and mild pain on palpation of her right lower extremity. T e V/Q scan comes back as nondiagnostic and the lower extrem- ity ultrasound is negative. Computed tomographic pulmonary an- giography vs ventilation- perfusion lung scanning in patients with suspected pulmo- nary embolism: a randomized controlled trial. Diagnostic strategy for patients with sus- pected pulmonary embolism: a prospective multicentre outcome study. Single-detector helical com- puted tomography as the primary diagnostic test in suspected pulmonary em- bolism: a multicenter clinical management study of 510 patients [published correction appears in Ann Intern Med. Use of a clin- ical decision rule in combination with d-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pul- monary embolism presenting to the emergency department by using a simple clin- ical model and D-dimer. Critical issues in the evaluation and management of adult patients presenting to the emergency department with sus- pected pulmonary embolism. Who Was Excluded: Patients with symptoms of angina, recent stress testing or coronary angiography, prior cardiac events, a markedly abnormal baseline electrocardiogram, or a limited life expectancy. Asymptomatic Adults with Diabetes Randomized Screening Cardiac Stress Testing No Stress Testing Figure 19. Study Intervention: Patients in the group assigned to cardiac stress testing received an adenosine-stress and radionuclide myocardial perfusion scan (see Figure 19. T ose with abnormal stress tests were managed according to the judgment of their providers (i. Patients in the control group did not un- dergo stress testing unless they developed symptoms for which stress testing was indicated. Secondary outcomes: unstable angina, heart failure, stroke, and coronary revascularization. T e pain began 3 days ago afer the patient spent the afernoon with her 1-year-old grandson. T e pain occurs on the lef side of her chest and back whenever she raises her arms above her head. She does not have any pain with walking, and she denies any associated symptoms such as shortness of breath, nausea, vomiting, or diaphoresis. You believe that this woman’s chest pain is musculoskeletal in origin, and that the probability of a cardiac etiology is remote. Still, the woman is at in- creased cardiac risk because of her diabetes, and could be having an atypical cardiac presentation. In other words, you probably wouldn’t “believe the results” if the stress test were to be positive. T us, ordering a stress test in this woman would likely have the same impact as ordering a stress test in an asymptomatic woman with dia- betes: there would be a 22% chance that the stress test would be abnormal, but knowing this information would be unlikely to aid in the patient’s treatment. It is possible that screening stress tests might be benefcial among a less well-managed cohort of patients. In addi- tion, because the event rate was lower than expected, the trial was underpow- ered to detect small diferences between the groups. Other Relevant Studies and Information: • Guidelines from the American Diabetes Association do not recommend screening for coronary artery disease in asymptomatic patients with diabetes,2 while the American College of Cardiology/ American Heart Association recommends exercise stress testing only among asymptomatic patients with diabetes who plan to begin an exercise program. However, detecting these abnormalities does not appear to aid in patient management. Funding: Toshiba Medical Systems, the Doris Duke Charitable Foundation, the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the Donald W. Year Study Began: 2005 Year Study Published: 2008 Study Location: Nine medical centers in seven countries (Brazil, Canada, Germany, Japan, Singapore, the United States, and the Netherlands). Who Was Excluded: Patients with Agatston calcium scores >600, history of cardiac surgery, contraindication to iodinated contrast, multiple myeloma, organ transplant, elevated serum creatinine or low creatinine clearance, atrial fbrillation, heart failure, aortic stenosis, percutaneous coronary intervention within past 6 months, beta-blocker intolerance, body mass index >40. How Many Patients: 291 Study Overview: Prospective, multicenter, international, blinded single- arm study. Two independent observers visu- ally assessed stenosis on images at a centralized core laboratory, and any in- terreader visual and quantitative diferences >50% were resolved by a third observer. Disease sever- ity was evaluated using a modifed Duke Coronary Artery Disease Index, with stenoses of ≥50% in any vessel greater than 1. Many of the exclusion criteria for this study are not necessarily criteria that would exclude other noninvasive diagnostic approaches (e. Another physician has recommended the procedure in order to determine whether he has signifcant coronary artery stenosis. T e diagnostic performance of multi-slice coronary computed tomographic angiography: a systematic review. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Funding: Commonwealth of Pennsylvania Department of Health and the American College of Radiology Imaging Network Foundation. Patients randomized to the traditional-care group had their care, including any tests, decided by their health care provider. Decisions about admission or discharge, further testing, and treatments were determined by the clinical team in both groups. Secondary outcomes included difering rates of discharge from the emergency department, length of hospital stay, and 30-day rates of re- vascularization and resource utilization. Criticisms and Limitations: Since myocardial infarction and death rates are very low, the study could not be powered to show between-group diferences in safety (e. His blood pressure is 120/80 mmHg, heart rate is 104, and he weighs about 160 pounds.
An abnormal response to exercise is defined by the development or worsening of regional myocardial function purchase doxycycline 200 mg antibiotics for acne clindamycin. Regional myocardial dysfunction cheap 200 mg doxycycline free shipping natural treatment for dogs fleas, as manifested by decreased endocardial excursion and wall thickening, is specific for myocardial ischemia. Decreased excursion alone is less specific and can occur with conduction abnormalities, with paced rhythms, and in the normal basal inferior myocardial segments. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. False-negative findings may occur with a delay in capturing postexercise images, low workload, or inadequate heart rate response (i. Additional causes of false-positive and false-negative findings are outlined in Table 47. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. The typical ischemic response to dobutamine is characterized by normal resting wall motion and an initial hyperdynamic response at low doses followed by a decline in function at higher doses. Ischemia may also be identified on the basis of deterioration of normal wall motion without any transient hyperdynamic response. The person who interprets the images must be well trained in order to develop an acceptable level of accuracy and must interpret an adequate number of studies on a regular basis to maintain accuracy. The ability to interpret stress echocardiograms is mitigated by image quality, the presence of arrhythmias, conduction abnormalities, respiratory interference from hyperventilation, and difficulty in reproducing the translational and rotational motion of the heart. Reported sensitivities and specificities (using coronary arteriography as the gold standard) vary between studies, depending on the prevalence of disease in the study population, the angiographic definition of significant disease, and the criteria used for a positive test. As with other imaging methods, the sensitivity is less for the detection of single-vessel disease and greater for the detection of multivessel disease. Myocardial perfusion scintigraphy is based on the detection of a perfusion defect during maximal hyperemia, with reduced perfusion of areas subtended by significant coronary artery stenosis (>50% stenosis). It may also be slightly superior for patients on antianginal therapy when it is necessary to induce ischemia. Local expertise, cost, exposure to radiation, and patient selection are all important factors in determining which imaging modality to use. Myocardial contractility ceases when 20% or more of the transmural thickness is ischemic or infarcted. Hibernating myocardium is characterized by viable, chronically ischemic noncontracting myocardium. Dobutamine infusion may result in augmentation of regional myocardial function predictive of recovery of function after revascularization. This is important prognostically, because revascularization of hypoperfused but viable myocardium improves survival. A contractile response to dobutamine requires that at least 50% of the myocytes in a given segment are viable. Demonstration of a biphasic response to low-dose (5 to 10 µg/kg/min) dobutamine strongly suggests viable myocardium. The initial improvement reflects recruitment of contractile reserve and hence viability. A biphasic response predicts eventual functional recovery of the myocardium after revascularization. A uniphasic response is less predictive of recovery, and a classic ischemic response is not predictive of the recovery of resting function. Because the biphasic response is the most reliable finding, the preference is to induce ischemia whenever possible by proceeding to maximal stress (40 µg/kg/min). When the wall thickness is <6 mm, there is a low likelihood of recovery of function. Concurrent use of β-blockers can reduce the number of viable segments detected and the sensitivity of testing. Second- generation microbubble contrast agents are small in diameter and reliably traverse the myocardial microvasculature. The microbubbles are destroyed with ultrasound energy, and the rate of microbubble replenishment represents mean red blood cell velocity and myocardial perfusion. Although subject to extensive research, this technology has had limited utilization in clinical practice and is not used routinely in most echocardiography laboratories. Perhaps the most important aspect of the prognostic literature is that a negative test result portends an extremely low risk of subsequent cardiovascular events, as evidenced by an event rate of <1% per year for the subsequent 4 to 5 years. However, the risk is slightly higher in patients with diabetes or chronic kidney disease. However, from the prognostic standpoint, the development of echocardiographic evidence of ischemia with dobutamine is analogous to its development during exercise. Heart failure is a more common end point among the group of patients with nonviable myocardium. Preoperative evaluation studies have been predominantly conducted with pharmacologic stress agents, primarily dobutamine. Transplant vasculopathy is a major cause of mortality after cardiac transplantation. Important prognostic information can be obtained beyond traditional wall motion analysis. Left atrial enlargement correlates with the chronicity 2 and severity of diastolic dysfunction. A normal resting left atrial volume index (<28 mL/m ) is strongly predictive of a normal stress echocardiogram. In many patients, “diastolic” heart failure is the dominant form of dysfunction, without any detectable systolic dysfunction at rest or during stress. The transmitral peak early diastolic velocity (E ) and the mitral annulus early diastolic velocity (e′) are utilized to assess the diastolic dysfunction. Exercise or adrenergic stress normally results in improved myocardial lusitropy (relaxation) to allow for better filling in a shorter amount of time. The tachycardia associated with exercise results in an abbreviated diastolic filling period and an increase in the transmitral peak Evelocity. In healthy patients, both the transmitral peak E velocity and the mitral annulus early diastolic velocity increase with exercise, and the E/e′ ratio is not changed. However, in patients with diastolic dysfunction, the mitral annulus early diastolic velocity is minimally affected by the change in preload caused by exercise and the E/e′ ratio increases. Assessment of diastolic dysfunction can be difficult at rest and is even more so with stress. However, evaluation is routinely performed using treadmill exercise or dobutamine.
Suicidal risk should be carefully assessed for any patient buy doxycycline 100mg mastercard antibiotics causing c diff, regardless of the “primary diagnosis” or the patient’s primary treatment request purchase doxycycline 100mg without a prescription antimicrobial lock solutions. In addition, the subjective expe- rience of suicidal thoughts or behavior may vary widely within the same patient in the course of his or her life or treatment, and it should always be considered as one of the primary risk factors for suicidal attempts. Developmental Context Even in adults, developmentally relevant aspects of symptom patterns interact with personality variables. A depression in an elderly woman may be experienced quite dif- ferently from a depression in a woman in her thirties, and it may consequently call for a different therapeutic approach. A formulation and treatment plan should recognize such age-related differences in addition to the patient’s history, individual life/rela- tional events, and social, economic and cultural context. Temporal Aspects of the Current Condition Why are these symptoms occurring now, and what do they mean? One technique is to wonder about the first and worst: If a man is depressed, when does he remember being depressed like this for the first time? Bimodal Symptoms Some symptoms were present at some discrete time in the past and reappear today. It may have been any item of “unfinished business” (fixation) from a person’s past, which becomes reactivated under stressful conditions or spe- cific life events—regression to a point of fixation—especially if the trigger has some thematic affinity to the original item. Sexual molestation in earlier childhood may have been perplexing, but may become more overtly traumatic retrospectively when puberty arrives, and the sexual intent suddenly becomes experientially clear (Freud’s Nachträglichkeit); or it may have been successfully repressed until a patient’s child reaches the age at which the patient was first abused. Interpersonal Functioning The family of origin is the original crucible where relationship patterns originate, whether in “objective fact” or in the patient’s personal perception. A simple way to elicit the subjective experience of relationship patterns with historical pertinence is to wonder how the patient relates/related to and takes after his or her mother and father. Contrasts sometimes emerge first, but it is worth pursuing identifications, as the most clinically pertinent ones are the ones most regretted: “I hate the fact that Mother always put herself first, and I find myself doing the same thing. This type of question- ing helps bring to light how primary relationships affect the patient’s current subjective experience. Comorbidity We do not assume that the presence of multiple symptom expressions inevitably con- stitutes “comorbidity” between different mental health disorders; we believe that more commonly, they are expressions of a basic complex disturbance of mental func- tioning. Each person’s symptom patterns, while sharing common features with similar patterns in other persons, have a unique signature. The clinical illustrations within each section of this chapter are intended to provide examples of specific patterns of internal experiences of some patients. The clinician is encouraged to capture each patient’s unique subjec- tive experience in a narrative form by considering the applicable descriptive patterns. In some instances, research findings support the observations that follow; in others, in the absence of empirical work on the topic, we have drawn on the combined clini- cal experience of therapists with expertise in each area covered. Symptom Patterns: The Subjective Experience—S Axis 139 Our approach also includes consideration of the biological contributions to some of these patterns and may even facilitate meaningful exploration of biological cor- relates for a variety of mental health disorders, as well as the complex interaction between psychological and biological factors. Psychological Experiences That May Require Clinical Attention For the purposes of this manual, we have thought it important to make room for a dis- cussion of the subjective experiences of particular groups whose members may come for mental health services because of difficulties associated with certain situations that are not pathological conditions. Consequently, this discussion is added as an appen- dix to this chapter’s main listing of the S Axis. The three groupings are demographic: ethnic, linguistic, and/or religious minorities; lesbian, gay, and bisexual communities; and those with gender incongruence. This is no longer diagnosed by subtype (paranoid, disorga- nized/hebephrenic, catatonic, undifferentiated, residual). This is now an independent specifier to be appended to another mental disorder or to another medical disorder. Just as for schizophreniform disorder, this move was intended to reduce the premature diagnosis of schizophrenia. Most researchers in schizophrenia, however, continued to regard it as within the “schizophrenia spectrum. Adult Symptom Patterns: The Subjective Experience—S Axis S1 Predominantly psychotic disorders S11 Brief psychotic disorder (Hysterical psychosis, Bouffée Délirante Polymorphe Aigüe) S12 Delusional disorder (Pure paranoia) S13 Schizotypal disorder (Simple schizophrenia, Residual schizophrenia) S14 Schizophrenia and schizoaffective disorder S2 Mood disorders S21 Persistent depressive disorder (dysthymia) S22 Major depressive disorder S23 Cyclothymic disorder S24 Bipolar disorders S25 Maternal affective disorders S3 Disorders related primarily to anxiety S31 Anxiety disorders S31. We focus on the most pertinent groupings: brief psychotic disorder (acute tran- sient psychotic episodes), delusional disorder (“pure paranoia”), and schizophrenia and schizoaffective disorder. Before describing the different diagnostic categories, we offer a methodological premise that may be helpful to the beginning professionals we regard as among our primary audience. Psychosis prompts a conflicting blend of horror and pity, cruelty and generosity in outside observers. The seeming alien quality of psychotic experience may persuade the clinician to give up trying to empathize with the patient’s subjective experience. Clinicians may phobically dismiss subjective experience and seek refuge in the self- reassuring certainty of diagnostic criteria and categorical classification. They would do well to train themselves to delay jumping to premature nosological conclusions, which then impede their capacity to appreciate their patient’s subjective experience. Clinicians as participant observers must immerse themselves in the seemingly odd and puzzling experience of the patient so as to rediscover the clinical wisdom embedded in Harry Stack Sullivan’s (1962) dictum: “We are all more simply human than otherwise. As “dissociation” has generally come to replace what had been “hysteria,” some prefer to consider brief psy- chotic disorder as “dissociative psychotic episode. What all these named conditions have in common are (1) an acute, rich, polymor- phous clinical presentation and (2) a relatively brief and self-limited clinical course. The latter characteristic—clinical course—is critical for differential diagnosis, though even this apparently simple characteristic may be difficult to ascertain exactly. Onset of symptoms is generally inferred from personal and familiar narratives, which can be biased by many factors, and their apparent remission can be influenced by several misleading factors, including a patient’s wish to seal over the psychotic epi- sode and the family’s collusion regarding the psychotic episode has ended. Once again, the clinician’s flexibility, openness of mind, and professional caution remain essential ingredients for the correct use of this diagnosis. Brief psychotic disorder is identified by the presence of symptoms of schizophre- nia (e. Personality disorders at the low borderline level of organization may predispose the individual to the development of this condition. Hysterical psychosis is described in the psychoanalytic literature as occurring usu- ally (but not necessarily) in individuals with “hysterical character” (now called “histri- onic” or “dysregulated”), and emerging within the context of specific severe stress and traumatic events, or as a transference reaction in an intensive psychoanalytic therapy (this last situation has been defined as “transference psychosis”). In hysterical psy- chosis, we may find severe distortions of reality testing, including delusions and even hallucinations, but no signs or symptoms generally attributed to schizophrenia (i. When this condition occurs in a treatment context, it may be confined there, or it may spill over into the patient’s ongoing life outside. As with any disorder, the clinician ought to be attentive to possible underlying dynamics: Do the symptoms seem to be obscuring or modifying some affective state? Does the transient flight from reality testing seem to be motivated by denial: (a reality Symptom Patterns: The Subjective Experience—S Axis 143 from which the patient is fleeing), or rather by wishful thinking (a wished-for reality to which the patient is fleeing)? S12 Delusional Disorder (“Pure Paranoia”) Emil Kraepelin divided the five major psychoses (catatonia, hebephrenia, mania, mel- ancholia, paranoia) into two groups, “manic–depressive insanity” (mania and mel- ancholia) and “dementia praecox” (catatonia, hebephrenia, paranoia), on the basis of clinical course: dementia praecox with a chronic deteriorating course, and manic– depressive insanity with return to a normal state between episodes.
Obstructive uropathy: Bladder neck obstruction by a calculus purchase doxycycline without a prescription antibiotic coverage chart, enlarged or inflamed prostate cheap doxycycline 100 mg with visa antibiotic resistant klebsiella pneumoniae, median bar hypertrophy, or urethral stricture is a condition to consider here. Neurogenic bladder from poliomyelitis, multiple sclerosis, and other spinal cord diseases must also be considered. Irritative focus in the urinary tract: Nocturia may result from inflammation of the bladder, prostate, urethra, and kidney on this basis. Inflammation of the vagina, fallopian tubes, and rectum are also occasionally responsible. Approach to the Diagnosis The workup of nocturia is essentially the same as the workup of polyuria and urinary frequency (see page 345). Venous pressure, circulation time, and pulmonary function studies to rule out congestive heart failure should be done if the urinary tract is clean. I—Inflammation prompts the recall of disorders that destroy the palate such as syphilis, leprosy, and tuberculosis. N—Neurologic disorders that paralyze the palate include poliomyelitis, Guillain–Barré syndrome, pseudobulbar palsy, brainstem tumors, and myasthenia gravis. T—Trauma should make one suspect palatal fenestration from gunshot wounds or surgery, posttonsillectomy weakness, and trauma to the brain stem. Approach to the Diagnosis Cleft palate and many other conditions will be diagnosed by a careful nose and throat examination; all that is necessary is a referral to an otolaryngologist. If the local examination is negative, a referral to a neurologist is probably in order. The muscles of the neck may be rigid from Parkinsonism or pyramidal tract disease. Diseases of the spine such as cervical spondylosis, rheumatoid spondylitis, and tuberculosis may cause nuchal rigidity. An acute fracture of the cervical spine should be considered if no history can 625 be obtained. The respiratory tree recalls retropharyngeal abscess, mediastinal emphysema, and endotracheal intubation. Finally, the spinal cord and meninges may be involved by meningitis, epidural abscess, subarachnoid hemorrhage, and primary and metastatic tumors, resulting in nuchal rigidity. Approach to the Diagnosis 626 The workup of nuchal rigidity requires a good history, but if one is unobtainable, no spinal tap should be performed until the cervical spine is x-rayed and the eyegrounds are examined. Even with a good history, a spinal tap should be withheld if there is papilledema: A neurosurgeon should be consulted immediately under these circumstances. In a patient with fever, nuchal rigidity, no papilledema, and no focal neurologic signs (particularly a dilated pupil), a spinal tap can be performed for diagnosis and immediate therapy. Meningitis or a subarachnoid hemorrhage is frequently found in these circumstances. The reason is that there are two forms of nystagmus (ocular and cerebellar) that do not necessarily occur with vertigo. In addition to these two categories, nystagmus that usually occurs with vertigo is divided into nystagmus of middle ear diseases, nystagmus of inner ear diseases, nystagmus due to auditory nerve involvement, and nystagmus due to brain stem and cerebral diseases. Ocular nystagmus: This is a pendular to-and-fro nystagmus with no fast component, which is usually due to congenital visual defects but which may be due to working in poor lighting (miner’s nystagmus). Middle ear disorders: Nystagmus may result from otitis media, which causes associated inflammation of the labyrinth. Inner ear diseases: Labyrinthitis may be viral, postinfectious, traumatic, or toxic (e. Auditory nerve: Acoustic neuromas, internal auditory artery occlusions, or aneurysms and basilar meningitis may be considered in this category. Thrombi, emboli, and hemorrhages in the branches of the basilar artery are important too. Dissemination encephalomyelitis and other forms of encephalitis should not be overlooked. Degenerative diseases such as syringobulbia and olivopontocerebellar atrophy are possibilities. Cerebellum: In addition to the causes of nystagmus mentioned under brain stem, the physician should consider cerebellar tumors, abscesses, posterior fossa subdural hematomas, and diphenylhydantoin toxicity, as well as Friedreich ataxia and other forms of hereditary cerebellar ataxia. Cerebellar degeneration associated with carcinoma of the lung is often misdiagnosed. Head injuries, encephalitis, chronic subdural hematomas, occipital meningiomas, and the aura of an epileptic seizure may also cause nystagmus. Nystagmus without other signs of central nervous system disease is usually ocular or peripheral in the middle or inner ear. Nystagmus with long tract signs such as hemiplegia or hemianesthesia is invariably brain stem in origin. Purely cerebellar nystagmus is not easily fatigued and is associated with dyskinesia and dyssynergia of the extremities as well as ataxia. Nystagmus with vertigo, nausea, vomiting, tinnitus, and deafness suggests Ménière disease. A spinal tap will help in the diagnosis of multiple sclerosis and neurolues as well as acoustic neuromas. Increased intake of calories: This type of obesity is due to an increased appetite. Under this heading are idiopathic obesity, psychogenic obesity, hypothalamic obesity (due to pituitary tumors and other lesions affecting the hypothalamus), islet cell adenomas and carcinomas (causing hypoglycemia and, consequently, a big appetite), early stages of diabetes mellitus when functional hypoglycemia is common, Cushing syndrome and exogenous corticosteroids (which increase appetite), and alcoholism, which not only stimulates the appetite but also adds calories in the alcohol (up to 250 calories per cocktail). Polycystic ovary syndrome causes increased appetite, but the hirsutism is a dead giveaway. Decreased output of energy: Under this heading should be listed hypothyroidism and possibly hypogonadism (such as Klinefelter syndrome), where the motivation to work or exercise may be impaired. Mild pituitary insufficiency (as in Sheehan or Fröhlich syndrome) may also cause obesity by this mechanism. Inappropriate antidiuretic hormone syndromes such as those that occur in carcinoma of the lung, hypothalamic lesions, and drugs are the most important obscure causes. Congestive heart failure, nephrosis, cirrhosis, beriberi, and myxedema rank as significant among the obvious causes. Miscellaneous causes: Heredity is a cause of obesity, but the physiologic mechanism is uncertain. Several drugs may cause obesity including corticosteroids, tricyclic antidepressants, selective serotonin reuptake 630 inhibitors, oral contraceptives, and estrogen. Approach to the Diagnosis It would be ridiculous to do a complete endocrine workup on every case of obesity, but thyroid function studies may be worthwhile. Patients who fail to lose weight on a strict diet may require hospitalization with observation. If they still fail to lose weight, a complete endocrine workup would seem to be indicated.