Der Internist
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Internists should expect to be the first contact for patients with rare, but highly contagious, life-threatening illnesses. Although certainly not encountered often, it is associated with significant consequences. Thus, physicians should be familiar with viral hemorrhagic fevers: filoviruses cause Ebola and Marburg fever, arenaviruses cause Lassa fever and South American hemorrhagic fevers, and the bunyaviruses cause among others Crimean-Congo hemorrhagic fever. Furthermore, physicians should be familiar with highly contagious respiratory infections, such as hantavirus pulmonary syndrome, pneumonic plague, and Middle East respiratory syndrome (MERS).
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Medullary thyroid carcinoma (MTC) is a very rare malignancy, which arises from parafollicular C cells and accounts for 3-5% of all thyroid cancers. MTC represents a neuroendocrine tumor with a biology that differs considerably from differentiated thyroid cancer. Presence of a RET proto-oncogene germline mutation indicates hereditary C cell disease in the context of multiple endocrine neoplasia type 2 and hence a special treatment algorithm is required. ⋯ Calcitonin screening is advocated for early MTC diagnosis and preoperative MTC management stratification. In case of surgically incurable persistent MTC, estimation of calcitonin and CEA doubling time is crucial to assess tumor biology and is complemented by multimodal imaging to assess tumor burden. Treatment decisions in incurable MTC must be carefully balanced with treatment-related morbidity, since MTC may take an indolent course over years.
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In addition to cardiac and pulmonary diseases there is a broad variety of different underlying causes of dyspnea. The spectrum includes the different forms of anemia, all causes of upper airway obstructions, neuromuscular diseases and psychopathological disorders. This article gives a brief review of the entire spectrum by providing information about differential diagnostics as well as the main therapeutic principles. A field of growing interest is dyspnea in the context of palliative care.
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The diagnostic pathway for the evaluation of patients with dyspnea requires a thorough history taking and physical examination. Based on the results of these basic steps a broad variety of additional diagnostic tests are available. ⋯ Among these are electrocardiography (ECG), laboratory parameters, X-ray examination, echocardiography, spirometry and whole body plethysmography and finally spiroergometry. This article presents a focused review of what each of these diagnostic modalities can contribute to the diagnostic process for dyspnea.
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The subjective perception of pulmonary dyspnea varies based on behavioral and physiological responses. Acute pulmonary dyspnea is the most common symptom of diseases of the airways and the lungs and the differential diagnosis includes harmless causes, such as lack of training as well as acute life-threatening diseases, such as thromboembolism, obstruction of the upper or lower airway, pneumonia, pulmonary hemorrhage and pneumothorax. Most cases of chronic pulmonary dyspnea result from asthma, chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, pulmonary fibrosis and pleural disorders. ⋯ Measurement of brain natriuretic peptide levels may help to exclude heart failure in COPD and D-dimer testing may help rule out pulmonary embolisms. Computed tomography of the chest is the most appropriate imaging procedure for diagnosing pulmonary embolism and interstitial lung disease. To diagnose pulmonary arterial hypertension echocardiography and right heart catheterization may be necessary.