A 58-year-old male complains of leg claudication. Subsequent tests reveal that he has significant bilateral peripheral arterial disease. His current medications include atenolol 50 mg/day, and aspirin, 325 mg/day. His blood pressure is 128/68 mm Hg, and his pulse rate is 64 beats/min. His LDL cholesterol level is 3.4 mmol/L.
The addition of which one of the following could reduce this patient’s symptoms?
Correct Answer C:
Peripheral arterial disease (PAD) is a common malady that has several proven treatments. The outcomes of these treatments can be separated into two primary categories: reducing PAD symptoms and preventing death due to systemic cardiovascular events (CVEs), especially myocardial infarction. Routine exercise up to near-maximal pain on a regular basis has been shown to be one of the most effective treatments for symptoms of PAD. Smoking cessation and aspirin are also standard recommendations, and can both prevent CVEs and slow the rate of progression of PAD symptoms. Statin drugs (specifically simvastatin and atorvastatin) have been shown to be beneficial for treatment of PAD symptoms and prevention of CVEs through the reduction of cholesterol, but they also appear to have other properties that help reduce leg pain in patients with PAD.
→ Although lowering abnormally high blood pressure is recommended in PAD patients, only ACE inhibitors have been shown to reduce symptoms of PAD directly. Furthermore, the combination of atenolol and nifedipine has actually been shown to worsen symptoms of PAD.
→ The addition of warfarin to aspirin has no additional benefit in either reduction of PAD symptoms or prevention of CVEs, but it may have a role in preventing clots in patients who have undergone revascularization.
A 60-year-old white female presents with pain in her left calf on walking. The pain does not go away with continued walking, and is relieved only by rest. She smokes a pack of cigarettes daily and has type 2 diabetes mellitus which is only moderately controlled with oral agents. She has been fairly noncompliant with dietary measures, and has not been interested in following your recommendations regarding medication for her hyperlipidemia. She is unable to do many of the things that she previously enjoyed doing, such as playing golf. Her ankle-brachial index at rest on the left is 0.60 and on the right is 1.10.
Which one of the following is shown to be most beneficial for this patient's peripheral vascular disease?
Correct Answer A: Exercise therapy for peripheral vascular disease (PVD) improves maximal treadmill walking distance and functional capacity. A rigorous exercise-training program may be as beneficial as bypass surgery and more beneficial than angioplasty. The goal LDL-cholesterol level in patients with established atherosclerotic vascular disease, including those with PVD (and all patients with diabetes mellitus) should be < 2.6 mmol/L (100 mg/dL). Tight control of diabetes mellitus has not been shown to favorably affect PVD.
What is the first indicator of impending foot gangrene?
Correct Answer A:
Chronic critical limb ischemia is manifested by pain at rest, nonhealing wounds and gangrene. Ischemic rest pain is typically described as a burning pain in the arch or distal foot that occurs while the patient is recumbent but is relieved when the patient returns to a position in which the feet are dependent.
Intervention may include conservative therapy, revascularization or amputation. Progressive gangrene, rapidly enlarging wounds or continuous ischemic rest pain can signify a threat to the limb and suggest the need for revascularization in patients without prohibitive operative risks. Bypass grafts are usually required because of the multilevel and distal nature of the arterial narrowing in critical limb ischemia.
Patients with diabetes are more likely than other patients to have distal disease that is less amenable to bypass grafting. Compared with amputation, revascularization is more cost-effective and is associated with better perioperative morbidity and mortality. Limb preservation should be the goal in most patients with critical limb ischemia.
A woman complains of early morning headache. She also has vomited a few times and has nystagmus. This has been going on for 6 months.
What is the next step in your investigation?
Correct Answer B:
Many symptoms result from increased intracranial pressure. The most common is headache. Headache may be most intense when patients awake from deep non-REM sleep (usually several hours after falling asleep) because hypoventilation, which increases cerebral blood flow and thus intracranial pressure, is usually maximal during non-REM sleep.
When intracranial pressure is very high, the headache may be accompanied by vomiting, which may occur with little preceding nausea. Papilledema develops in about 25% of patients with a brain tumor but may be absent even if intracranial pressure is increased. In infants and very young children, increased intracranial pressure may enlarge the head. If intracranial pressure increases sufficiently, brain herniation occurs.
If an intracranial mass is suspected, a CT or MRI of the head/brain should be done.
A 35-year-old male who works as an EMT has recently developed deep, severe, continuous headaches behind his left eye. The headaches occur daily around 10:00 a.m. and last 1-2 hours. He notes that the headaches bother him less when he remains active. When the headaches occur he also has tearing from the left eye and a nasal discharge from the left naris.
He has found that using oxygen gives him relief. A physical examination reveals no significant findings.
Which one of the following would be most appropriate at this time?
Correct Answer E:
Cluster headaches are repetitive headaches that occur for weeks or months at a time. They are more common in men between the ages of 30 and 50. The headaches begin without warning and reach a crescendo within minutes. Most times the headaches are located behind the eye or at the temple, and are associated with ipsilateral lacrimation, redness of the eye, nasal stuffiness, sweating, pallor, and Horner’s syndrome. Patients note that they are sensitive to alcohol. They often prefer to remain active rather than rest in a dark, quiet room as someone with a migraine would likely do. A typical attack will last from 30 minutes to 3 hours. It is common for the pain to recur each day at the same time. These attacks occur 1-3 times a day over a 4- to 8-week period. The patient will often remain pain-free for 6 months to a year.
A cluster headache can be distinguished from a migraine, a tension-type headache, and a brain tumor by its presentation. Headaches associated with a brain tumor are often accompanied by nausea, vomiting, and worsening of the pain (which is usually bifrontal) with change in body position. There are usually positive findings on neurologic examination, as well as a change from the previous headache pattern. Migraines are more common in women and may be associated with an aura. They are throbbing in nature and accompanied by nausea, photophobia, and phonophobia. These patients are usually much more comfortable in the dark. Both cluster and migraine headaches will respond to abortive therapy with triptan medications.
Prophylaxis for migraine is normally begun if there are four or more attacks within a month. In contrast, once the diagnosis of cluster headache is made, it is important to initiate both abortive and prophylactic therapy right away. Abortive therapy can be with 100% oxygen, triptans, octreotide, or dihydroergotamine. A number of prophylactic medications are available, including verapamil, lithium, prednisone (short-term use only), ergotamine, cyproheptadine, and indomethacin.
Click to expand