doc_clotaire
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A 39-year-old Polish man comes to the clinic for painful calves after
walking long distances and for discoloration of the fingers with
changes in temperature. He says his symptoms started two months ago,
and he gets no relief from the ibuprofen. He has previously been
healthy. He currently smokes a pack a day and drinks socially. He has
no history of drug abuse. On physical examination, his blood pressure
is 140/90 mm Hg, heart rate is 68/min, and he is afebrile. Examination
of the hands reveals distal digital ischemia and trophic changes in
the nails of both hands. Radial pulses are absent bilaterally, but all
other pulses are present. His right calf shows evidence of a
superficial thrombophlebitis. Laboratory studies show: white cell
count 9,600/mm3, hematocrit 38.6%, MCV 89 μm3, ESR 40 mm/h, and
C-ANCA as negative. The rheumatoid factor and ANA are negative. Which
of the following should be done next for this patient?
(A) Heparin
(B) Prednisone
(C) Arterial bypass
(D) Cyclophosphamide
(E) Abstention from tobacco
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| muzammil
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e
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| sprint123
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I think E....Can anyone elaborate the protocol of beurger's?
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| Justice
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(E)
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| docnikki
Forum Guru
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I think E too.
Beurger ds---> never only to one limb., digital involvement is symmetrical,
vein and artery inflammation is segmental..rest pain and dec sensations due to ischemic neurpathy
distal pulses absent proximal intact ( as opposed to atherosclerosis)
also claudication that starts from arch of foot and gets up to calves.
h/o migratory superficial thrombophlebitis
often h/o or raynauds phen
The clinical course is episodic.
GL
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| docnikki
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treatment...firstsmokng cessation
aspirin plus another antiplatelt prescribed
calcium channel blockers to promote vasodialtion supplementary O2.
sympathetectmy can transiently reduce the vasospastic manifestations...its for intractable rest pain and healing of refractor ulcers. Its often performed with digital amputation.
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| dr.wad
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( E )
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| doc_clotaire
Forum Guru
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Answer:
(E) Abstention from tobacco
Explanation:
This patient has thromboangiitis obliterans (Buerger's disease), which
is an inflammatory occlusive disorder involving small and medium-sized
arteries and veins in the distal and upper extremities. The prevalence
is highest in men of Eastern European descent under the age of 40.
Although the cause is unknown, there is a definite relationship to
cigarette smoking and an increased incidence of HLA-B5 and -A9
antigens in patients with this disorder. Clinical features of
thromboangiitis obliterans often include a triad of claudication of
the affected extremity, Raynaud's phenomenon, and migratory
superficial thrombophlebitis. Claudication is confined to the lower
calves and feet or forearms and hands because this disorder primarily
affects the distal vessels. Hand examination can reveal severe digital
ischemia, trophic nail changes, ulceration, and gangrene at the tips
of the fingers. Brachial and popliteal pulses are usually present, but
radial, ulnar, and/or tibial pulses may be absent. Smooth, tapering,
segmental lesions in the distal vessels are present on angiography.
The diagnosis can be confirmed by excisional biopsy of an involved
vessel. There is no specific treatment, except abstention from
tobacco. The prognosis is worse in those who continue to smoke, but
results are relatively good in those who stop. C-ANCA antibodies are
usually found in Wegener's granulomatosis. Arterial bypass may be
indicated in disease confined to larger vessels. The hand
abnormalities effectively exclude peripheral vascular disease. If
these measures fail, amputation may be required. Cyclophosphamide and
prednisone do not help. Again, the management is to stop smoking.
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