UW - disagree with the answer

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UW - disagree with the answer

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Doc750
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12/25/07 - 09:41 AM

I know everyone has uw questions/answers memorized. So please don't post an answer without an explanation.

63 year old male with 6 month hx of severe pain in both legs whenever he walks more then a block. The pain consistently occurs after one block of walking & is relieved by rest. No nocturnal pain or pain at rest occurs. Hx of HTN, DM, and hypercholesterolemia. Pt is a heavy smoker. Pt takes amlodipine, ramipril, atorvastatin. BP 150/90, pulse 70. Exam shows hair loss of lower legs. Bilateral brittle toe nails. Femoral and ppopliteal pulses are weak but present. Distal pulses absent bilaterally. What is the most appropriate next step in management of this patient?

A. Angiogram to determine the extent of disease

B. Surgical revascularization

C. Aspirin/ exersize

D. Sympathectomy

E. Angioplasty

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Doc750
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12/26/07 - 08:32 AM

no one huh ..... disapproval

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arlete
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12/26/07 - 09:54 AM

It's C. The intention is to improve the collateral circulation to the diseased area (increase in oxygen demand leads to increased neovascularization). The aspirin is an antiplatelet drug, decreases clot formation.

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Doc750
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12/26/07 - 10:22 AM

that's what UW says as well. But in the stem it says that distal pulses are absent. So I'm thinking if distal pulses are absent then you need to do an angiogram. Then in the explanation UW says that one of the indications for an angiogram would be absent pulses.

Minor side point: In addition the guy can only walk one block before getting severe pain. What kind of exersize program are you going to put him on when he can only take 30 steps before having severe pain.

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arlete
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12/26/07 - 11:33 AM

One with 31 steps.

What's the point in doing an angiogram when the diagnosis is already so clear, and the treatment is not surgical? (I am not being ironic, I want to understand your point). smiling face

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Doc750
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12/26/07 - 11:57 AM

arlete wrote:
One with 31 steps.

lol

arlete wrote:
What's the point in doing an angiogram when the diagnosis is already so clear, and the treatment is not surgical? (I am not being ironic, I want to understand your point). smiling face

Absence of distal pulse is what they had in the stem. Then in their explanation they say the same thing I'm saying that indication to do an angiogram is abscence of a pulse. Yes the diagnosis of intermitent claudication is #1 of d/dx. But I figured you'd want an angiogram to confirm your diagnosis.

and if for no other reason then to bill the client's insurance for another procedure.

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CocaCola
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12/26/07 - 12:10 PM

Doc750 wrote:

and if for no other reason then to bill the client's insurance for another procedure.

nothing should ever interfere with our bottom line...

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hero
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12/26/07 - 12:53 PM

look at qs

The pain consistently occurs after one block of walking & is relieved by rest
No nocturnal pain or pain at rest occurs.

not too bad. (assuming heavy smoking), surgical intervention in this setting is not indicated.

exercise is - walk - rest - walk again

arlete
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12/26/07 - 01:42 PM

doc750

I like your argument...

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