Cardiovascular Disease

A preoperative evaluation performed shortly before a 66-year-old man is scheduledto undergo coronary artery bypass graft (CABG) surgery reveals a peripheralblood leukocyte count of 23,500/μL with 28% neutrophils, 70% lymphocytes,and 2% monocytes. The patient’s hemoglobin level is 14.5 g/dL; plateletcount is 265,000/μL.

For over 25 years, NSAIDs have been used to treat a variety of pain syndromesand inflammatory diseases. More than 50 million Americanstake these drugs. Unfortunately, control of pain and inflammation is notachieved without an associated cost-namely, GI complications and, to a lesserextent, nephrotoxicity.In an attempt to reduce drug-related toxicity, a new class of selectiveNSAIDs-the COX-2 inhibitors-was introduced in 1999. These selectiveNSAIDs are as effective as and pose less risk of gastric toxicity than nonselectiveNSAIDs.1,2The COX-2 inhibitors are thought to reduce end-organ injury, such as GIulceration, by sparing homeostatic or “constitutive” COX-1 enzyme function.1,2 Incontrast, therapeutic effects result from the inhibition of the “inducible” COX-2enzyme.1,2 Such drug effects target the production of proinflammatory prostaglandinsby COX-2 without interrupting normal cell function mediated by COX-1.2,3

This simple technique can quickly reduce leg edema.

A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.

What is the recommended treatment of a patient who has anasymptomatic splenic aneurysm that is 4 cm in diameter?

If elderly patients or those withchronic lung disease have troubleholding their breath in while you tryto listen for carotid bruits, have themtake a deep breath, exhale, and holdtheir breath out.

My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled.

A 59-year-old woman complainsof progressively worsening bloatingand right upper quadrant pain thatbegan 1 day earlier. She denies feverand trauma. Her medical history includescholecystectomy for cholelithiasisand several emergency departmentvisits for treatment of woundssustained in falls. She has a history ofalcohol abuse, for which she now receivescounseling. However, she admitsthat she occasionally has boutsof heavy drinking.

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

A 59-year-old woman presents with generalized facialswelling and dyspnea that has progressed graduallyover the past month. The patient also reports a sensationof pressure in her neck and ears and swelling of the lowereyelids, neck, upper chest, and upper limbs. The bloodvessels on her upper chest are prominent. A dry, irritatingcough has worsened.

I recently diagnosed type 2 diabetes mellitus in a 33-year-old man who has no diabeticsymptoms, proteinuria, or evidence of nephropathy. His blood pressure is low(100/60 mm Hg).

A 48-year-old African Americanwoman with HIV infection who hadbeen hospitalized several days earlierfor presumed Pneumocystis cariniipneumonia (PCP) is readmittedbecause of worsening dyspnea and atemperature of 38.8oC (102oF).She also complains of painful swellingand erythema on her right arm.Her symptoms have worseneddespite treatment with trimethoprimsulfamethoxazole.

A 55-year-old constructionworker who spends a gooddeal of time outdoors has had occasionalblurred vision and an irritatedeyelid for several days. He has wellcontrolleddiabetes and hypertension.Which of these conditions doyou suspect?

A 51-year-old man presents with aseverely infected leg and 1- to 2-cmlesions on all of his extremities andtrunk; the bases of the lesions aredepressed, atrophic, and scarred.According to the patient, the lesionstypically appear as tender nodulesor pustules, which spontaneouslyburst, drain purulent material, andeventually heal as pictured.

In Dr Sean Eric Koon's Case In Point, "Puzzling Rash in an Older Woman"(CONSULTANT, April 15, 2003, page 629), I agree with his conclusion that thispatient had cutaneous leukocytoclastic vasculitis (CLV) (Figure). I also agreethat she met the American College of Rheumatology's 1990 criteria for a diagnosisof hypersensitivity vasculitis.1 However, given the patient's history and laboratoryresults, I believe further evaluation was warranted to determine whether the medication was indeed to blame for her CLV or whether an underlying systemicdisease was responsible.Her white blood cell (WBC) count was 72,000/?L. CLV is known to producea mild leukocytosis--presumably caused by the inflammatory response of the vasculitis.Thus, one would expect to see only a slight elevation in the WBC count.Also, if the elevation had been produced by the inflammatory response of the CLV,the patient's erythrocyte sedimentation rate (ESR) would have been significantlyelevated. However, her ESR was 12 mm/h, which is essentially normal in awoman this age.The discovery of a value that is not consistent with the disease process makesme question Dr Koon's final diagnosis--or at least want to add to his differentiala disease that could be responsible for both the CLV and the level of leukocytosisseen here: hairy cell leukemia.Other facts in the case that tend not to support the conclusion that the patient'sCLV resulted from a drug reaction include the following:One would expect to see systemic symptoms, such as fever, malaise, anorexia,and/or myalgias if a drug reaction caused the CLV; this woman reportedly didnot experience any of these.Rashes associated with CLV produced by a drug reaction are generally describedby patients as pruritic, painful (sometimes significantly so), and/or associatedwith paresthesias, such as a burning or stinging sensation; this patient's rash isdescribed as "painless and nonpruritic."Thus, although an exogenous agent such as trimethoprim-sulfamethoxazole(TMP-SMX) can cause CLV, it would have been prudent in view of the findingsin this case to search for an endogenous cause, such as an underlying systemicdisease or malignancy.----Pamela Moyers Scott, MPAS, PA-CWilliamsburg, WVaThank you for your comments. You detected a typo; this patient's leukocytecount was actually 7200/?L. A value of 72,000/?L would indeedbe of concern and would prompt a new differential diagnosis. HerWBC count when last checked was 7300/?L.Ultimately, my determination was that the patient's rash was mostlikely triggered by a viral infection and not by the TMP-SMX. I felt that anotherhealth care provider had inappropriately treated her upper respiratory tractinfection with an antibiotic, so I stopped the medication. Because I could notcompletely rule out the antibiotic as a cause of this potentially serious condition,I recommended that she avoid it in the future. This is yet another exampleof how the treatment of colds with antibiotics can confuse the clinical pictureand possibly harm the patient.--Sean Eric Koon, MD  &nbspFontana, Calif

A 68-year-old man with severe emphysema complains ofchest pain that began that morning. He has also had intermittentdiarrhea and occasional blood in his stool for thepast 2 weeks.

In his article, “Subclinical Hypothyroidism: When to Treat, When to Watch?”(CONSULTANT, April 1, 2004, page 533), Dr Vahab Fatourechi notes that thereis some evidence that subclinical hypothyroidism has adverse effects on cardiovascularfunction that may contribute to left ventricular systolic dysfunction with effort.

A 2-month-old infant is brought to the office by his parents becausehe has been crying inconsolably for the past 4 to 5 hours. The childhas been well since birth and has no history of vomiting, diarrhea, fever, orrash. The infant is being breast-fed, is not taking any medication, and hasnot been in contact with any sick persons.

In his article, "Dyslipidemia: Closing the Treatment Gap"(CONSULTANT, April 1, 2003, page 451), Dr David Nashrecommends statin therapy for all eligible elderly patients.

A46-year-old white man is hospitalized with increasing dyspnea of 3weeks’ duration. He has a history of stable chronic obstructive pulmonarydisease secondary to heavy smoking (2 packs of cigarettes a day for 27years, discontinued 6 years previously) and uses inhaled bronchodilators.

In their case report of a woman withsuperior vena cava syndrome (CONSULTANT,September 15, 2002, page1391), Drs Sonia Arunabh and K.Rauhilla appropriately indicate thatradiation therapy is the primary treatmentwhen the syndrome is caused bysolid malignancies.

A 38-year-old overweight woman presents with an asymptomatic rash ofat least 2 months’ duration that had not responded to a combinationcorticosteroid/antifungal agent. She has mild hypertension and type 2 diabetesmellitus that is being managed with diet and exercise. She is otherwisehealthy.

I enjoyed the article by Dr Ronald Crock, “Herbal Medicine: Top 5 HerbsYour Patients Take . . . But Don’t Tell You” (CONSULTANT, September 1,2003, page 1199).

When a patient with diabetes presentswith a foot wound, prompt and aggressiveintervention is required topromote healing and to prevent progressionthat could lead to a leg amputation.Fortunately, the majority ofdiabetic foot wounds heal rapidly withlittle difficulty.

Men and women with diabetes are 2 to 4 times more likelythan other persons to die of complications of cardiovasculardisease (CVD). Solid evidence from primary andsecondary prevention trials has prompted the AmericanDiabetes Association to recommend low-dose aspirin therapyfor patients with diabetes who either have or are athigh risk for CVD (Table).

A 7-year-old girl presents for evaluation of a pink, polypoid, 2 x 2-mm lesionon her inner lower lip, which has been present for several weeks. The child isasymptomatic and denies any trauma to the mouth.

Intermittent, worsening confusion recently developed inan 82-year-old man. His daughter brings him to the officefor evaluation.

A 64-year-old woman complainsof neck fullness that has increased inthe last few months. She has occasionaldyspnea but denies fever, cough, andhemoptysis. Hypertension is well-controlledwith propranolol.

To visualize the capillary pulsationsof aortic regurgitation, stretch the patient’slower lip out and carefully encloseit between 2 glass slides.

An 84-year-old man complains of worsening angina pectoris that started3 months earlier. The patient has had aortic stenosis for about 10 years. Healso has diabetes, which is controlled with oral agents.