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Heightened awareness of endocrine abnormalities is important in evaluation of patients presenting with musculoskeletal symptoms. Endocrine disorders such as diabetes, hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoparathyroidism, hyperadrenocorticism, and acromegaly cause a unique array of rheumatic manifestations. Such conditions include Dupuytren's contracture, carpal tunnel syndrome, chondrocalcinosis, pseudogout, scleredema, and osteoporosis. Characteristic changes on radiologic evaluation and serum enzyme testing are additional clues to these atypical presentations. Consideration of a possible endocrine cause early in the evaluation may improve management in patients with such an underlying disorder.

Systematic evaluation of each patient with refractory hypertension is necessary to identify conditions or altered mechanisms of hypertension that are amenable to targeted therapy. Issues that should be carefully investigated are appropriateness of the regimen, possible drug interactions, patient compliance, associated conditions (alcohol or recreational drug use, hyperinsulinemia), pseudohypertension, office hypertension, and volume overload. When these problems are eliminated, causes of secondary hypertension should be sought, the most common being coarctation of the aorta, Cushing's syndrome, primary aldosteronism, pheochromocytoma, renovascular disease, thyroid and parathyroid disease, and renal parenchymal disease. In a few cases, a careful hemodynamic and neurohumoral assessment is needed to direct treatment. When the recommended stepwise workup is followed, hypertension that is truly refractory to treatment is a rare finding.

The primary clinical characteristic of shortness of stature due to endocrine deficiency is a slow rate of growth (less than 1.5 in., or 4 cm, each year). Dental and skeletal ages are delayed. Specific tests of thyroid and pituitary function must be done to document the deficiency. Replacement therapy with levothyroxine or human growth hormone, or both, should be given as indicated. Short children who do not have hormone deficiency grow about 1.5 in. (4 cm) each year but have normal skeletal and dental ages. Children with Turner syndrome, primordial or genetic short stature, or intrauterine growth retardation do not respond to levothyroxine or human growth hormone replacement therapy. Constitutional delay in sexual development is a common cause of short stature in adolescent males and must be differentiated from hypopituitarism.

Endocrine causes of male infertility range from easily manageable disorders such as hypothyroidism to complex problems such as pituitary tumors. Proper management requires a thorough understanding of the hypothalamic-pituitary-testicular axis. Hormonal evaluation is performed only when the patient's history and results of physical examination indicate an endocrine problem. With proper identification and treatment, most of these problems can be successfully managed.

Endocrine disorders are important, potentially reversible causes of impotence. Impotence may be an early manifestation of hypopituitarism, nonfunctioning pituitary tumors, prolactin-secreting pituitary tumors, or hyperthyroidism. Treatment of these disorders, as well as many of the other endocrinopathies with which impotence may be associated, usually leads to restoration of libido and potency. When impotence is caused by the autonomic neuropathy of diabetes, however, treatment of the endocrinopathy rarely restores sexual function. Sex therapy or implantation of a penile prosthesis may be useful in selected patients with this cause of impotence.

Short stature is less likely to have an endocrine basis than is commonly thought. Any of a number of chronic systemic diseases can slow growth, short stature may result from a genetic tendency or disorder, growth may be constitutionally delayed, or it may be retarded by intrauterine influences. True endocrine causes include thyroid or adrenal disorder, growth hormone deficiency, and psychosocial dwarfism. Although growth hormone deficiency is quite rare, it has received increased attention recently. The capability to produce human growth hormone by recombinant DNA techniques presents the prospect that replacement therapy will be more readily available to those patients who might benefit from it. Caution is called for, however, in making use of this agent for patients other than those with proven growth hormone deficiency.

Because cancer and its treatment have so many effects on the CNS, the diagnosis of psychiatric symptoms in cancer patients is problematic. Naturally there are psychologic and psychosocial issues that often sufficiently explain why a patient appears distressed. Dealing with psychologic adjustment is always an important part of the management of patients with severe medical, as opposed to psychiatric, illness, whether or not biologic components of the psychologic problem can be identified and addressed. The most frequent error physicians make in evaluating psychiatric symptoms is to assume that a psychologic explanation is sufficient. Expressions such as "Wouldn't you be depressed if you had cancer?" are often used to excuse failure to pursue further evaluation. Careful reviews of cases in which cancer patients were labeled as having psychologic problems have consistently shown a high incidence of misdiagnosis. Correct diagnosis and treatment of an underlying organic disorder can alleviate symptoms that impair the patient's innate coping resources, allowing him or her to grapple more effectively with adverse circumstances.

Diabetes control is especially important when the patient is undergoing surgery, as the trauma can result in major metabolic changes. Complications of diabetes must be assessed preoperatively, since they themselves can lead to the need for surgery or can predispose to increased surgical or anesthetic risk. The preoperative blood glucose status of diabetics can be assessed by use of standard laboratory methods, self monitoring devices, urine glucose testing, or measurement of glycohemoglobin level. Blood glucose control can be maximized by designation of one physician on the health care team to be in charge of fluid, electrolyte, and insulin administration on perioperative days. This physician should follow a definite protocol of subcutaneous insulin administration guided by appropriate monitoring of blood glucose response. In special cases, such as surgery in the pregnant diabetic, a more complex scheme of management using low-dose insulin infusion may be required. Coexistence of another endocrine disease with diabetes should be recognized, since it may lead to otherwise unexpected changes in insulin requirements. A systematic and comprehensive yet flexible approach to the treatment of diabetes before, during, and after surgery puts a successful outcome well within the reach of the modern clinician.