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  #1  
Old 08-08-2011
podebrad's Avatar
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Default Painful Calves

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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  #2  
Old 08-08-2011
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May be heparin , Not sure ...
I know we use heparin in DVT .. but not sure about superficial thrombophlebitis..
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Old 08-08-2011
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Quote:
Originally Posted by podebrad View Post
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
its E ...i am thinking he has bergers...its an immune disease so prednisone and cyclo are out...Heparin is not use in superficial thrombophlebitis...he has claudication which i guess u can stop tobacco as a first thing of order and if not then maybe arterial bypass for the locations effected....
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Old 08-08-2011
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actually I'm not sure but here is what I'm thinking...

he has no clues that he has DVT and the problem is in his hands and calves so no heparin at the moment...

As for the Berger disease... It's not likely cuz he is European and I read somewhere that it's not very common in European countries (It's mostly common in the Middle east) but as an initial treatment we could advice him to cut down on cigarettes but again his problem seems critical (1. discoloration , no pulse is felt ,signs of chronic etiology due to ischemic changes in the nails and pain) so maybe it's good to do a bypass but I'm not sure...

Cortisol and Cyclophosphamid are not good options cuz it doesn't seem autoimmune
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  #5  
Old 08-08-2011
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this is seems to be thromboangiitis obliterans (Buerger's disease) , triad of claudication , Raynaud's phenomenon, and migratory superficial thrombophelebitis .. i dunno about absent of the radial pulse .. but no specific treatment .. tho stop smoking is a good choice
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Old 08-10-2011
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The answer is E. Will post the explanation soon.
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Old 08-11-2011
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(E) Abstention from tobacco i think burger
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