QUESTION: 165

A74-year-old male with a history of hypertension, CAD, and a 50 pack-year history of smoking presents with complaints of pain and cramping sensation of the thigh and buttock areas for the past 2 months. On detailed history, patient reports that the pain is usually during ambulation and relieves with sitting down. The pain does not change with respect to sitting or supine position. He denies any recent trauma, weakness of the legs, or paresthesias. He takes his prescription medications regularly and denies using alcohol, drugs, or any herbs/ supplements. Which of the following should be performed as an initial test to help confirm your clinical impression?

Which of the following measures should be implemented for the management of this patient's condition?

referral to vascular surgeon
glucosamine and chondroitin sulfate
subcutaneous injections of low molecular weight heparin
smoking cessation and walking program
pentoxyfylline

Answer(s): D

Explanation:

Peripheral arterial disease (PAD) affects roughly 12% of the U.S. population with higher prevalence rates in persons over the age of 70. The classic symptoms of PAD are intermittent claudication which is usually described by patients as cramping pain in the calf, legs, thighs, or buttocks during any type of exercise that quickly relieves with rest. This scenario of worsening with activity and relief with rest is consistent with the disease process, as the pain results from ischemia. The ischemia is worse during periods of increased oxygen demand where the vascular insufficiency fails to meet the demand. Not all patients with PAD are symptomatic, thus an assessment of risk factors and a thorough physical examination are usually key to making the diagnosis in asymptomatic patients. The ABI is an easy, inexpensive, noninvasive test with a high correlation to angiography that can be done in the office. ABI is the usual initial test to screen for PAD.

A value of greater than 1.0 is considered normal, whereas values less than 0.9 are consistent with varying grades of PAD:

· 1.0 or greater: normal
· 0.810.9: mild PAD
· 0.510.8: moderate PAD
· <0.5: severe PAD
The sensitivity of the ABI can be increased if performed post exercise. The ABI, however, has its limitations in patients with noncompressible, calcified vessels such as the elderly or in patients with diabetes. An ABI of greater than 1.3 may suggest the above scenario and its utility would be suspect. In these cases, more detailed testing may be warranted. Other modalities to assess PAD include arterial Dopplers, magnetic resonance angiography, and conventional angiography. The initial therapy for patients with PAD should be a trial of a structured walking program along with smoking cessation. Walking programs have been shown to increase walking distance without symptoms. In addition, walking also improves endothelial function, collateral vessel formation and function, and control of blood pressure, lipids, and blood sugars.

Pentoxyfylline has been traditionally recommended for PAD; however its efficacy is modest at best based on newer trial data. Antiplatelet agents may also be added for PAD as it will improve cardiovascular risk and perhaps modify the pathogenesis for PAD. Ultimately, risk factor modification is key for prevention and reduction of complications and comorbidities. Severe PAD or patients who require more specialized intervention may require vascular surgery consultation.

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QUESTION: 166

A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure.

Which of the following physical examination findings are you most likely to find in this patient?

prolonged expiratory phase of respiration
supraclavicular adenopathy
rales one-quarter of the way up in both lungs
clubbing of fingers
prominent first heart sound

Answer(s): A

Explanation:

COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.

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QUESTION: 167

A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure

Which of the following is most likely to be found on a CXR?

cardiomegaly
residual infiltrate from inadequately treated pneumonia
a pulmonary mass with hilar adenopathy
hyperinflation of the lungs
Kerley B lines

Answer(s): D

Explanation:

COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.

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QUESTION: 168

A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure

You recommend smoking cessation to your patient. She asks why, at this point, she should quit. Which of the following statements is true?

Her pulmonary function will improve 50% or more if she quits.
Quitting will not affect her pulmonary status but may reduce her risk of having a heart attack.
At this point, quitting will not improve her survival.
She is going to require supplemental oxygen and smoking will represent a significant fire hazard.
If she is able to stay off of cigarettes, the rate of worsening of her lung function will slow.

Answer(s): E

Explanation:

COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.

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QUESTION: 165

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