Hyperphosphatemia in a 56 year-old man with hypochondrial pain
CASE 215: A 67 YEAR OLD WITH A PAIN IN THE BUTT. History A 67-year-old gentleman is admitted...
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Transcript of CASE 215: A 67 YEAR OLD WITH A PAIN IN THE BUTT. History A 67-year-old gentleman is admitted...
CASE 215: A 67 YEAR OLD WITH A PAIN IN THE BUTT
History• A 67-year-old gentleman is admitted complaining
of a dull aching pain in the right buttock and right thigh. The pain is making it impossible for him to walk. Four years ago, the patient had an episode of severe chest pain. Heart catherization at the time showed a lesion on the left anterior descending coronary artery which was dilated with balloon angioplasty. The patient also states that there has been pain in the legs after walking more than one block over the past two years, but generally he has modified his life style to avoid walking.
P. E• an anxious individual with severe leg pain; his pulse is 84
and regular, resp. 16, temp. 38°C, • HEENT is negative except for arcus senilis and a faint left
carotid bruit. • Chest examination reveals occasional rhonchi but no
rales. • The heart exam is essentially normal. • Abdominal exam is unremarkable. • Lower extremities show loss of hair below the knees
bilaterally and the skin is shiny and irregularly pigmented. There are no ulcerations and no skin temperature differences. The right leg is slightly dusky.
PulsesPulses: Radial Femoral Popliteal Post-
tibialDorsalis pedis
Left 3+ 3+ 3+ 2+ 1+
Right 3+ 3+ 1+ 0 0
What is the your problem list and admitting diagnosis and differential? What laboratory tests would you order now?
Labs• CBC: Hgb: 14g/dL Hct:
45% RBC: 5.0x106/μL WBC:7.0x103/μL
• Sodium: 140 mMol/L Potassium: 3.8 mMol/LHCO3-: 25 mMol/L Chloride: 100
mMol/Lglucose 120 mg/dLBUN 21 mg/dL Calcium: 10.0 mg/dL Phosphorous: 3.0 mg/dL Protein:
7.5 mg/dL AST: 39 IU/LCholesterol: 260 mg/dL Triglycerides:
390 mg/dL HDL: 32 mg/dLInterpret the lipid findings and what would you do about them.Any changes to you differential. What would you order now?
•
Vascular ultrasound showed severe obstructive atherosclerosis of the iliac and femoral arteries with almost complete occlusion. The vascular surgeon performed a ilio-popliteal bypass. There was initial good perfusion of the leg. The patient was released and counseled as to the necessity to stop smoking, modify his diet, and lose at least 25 pounds. One year later, the patient came in with a numb, cold right leg. Angiography showed occlusion of the distal part of the graft. The vascular surgeon and interventional radiologist attempted to angioplasty the distal portion of the graft and a portion of the distal popliteal artery. After one week of intensive anticoagulant therapy, they found it was impossible to maintain the patency of the graft and distal popliteal artery. Irreversible ischemia developed and the leg had to be amputated.
The specimen
Section of the anterior tibial artery
Trichrome elastic stain :
Internal elasticmembrane
Intimal plaque
Should be lumen
Another area of the ant. tibial artery
Calcification
Muscle atrophy and degeneration
Early Gangrene
What type of necrosis is going on here?
What is Leriche’s syndrome?
How do you distinguish arterial from venous peripheral vascular disease?
What role do the following play in peripheral vascular disease:
Diabetes and smoking
Distinguish atherosclerosis obliterans from thromboangiitis obliterans.
Thromboangiitis obliterans-Buerger’s disease
Diabetic vascular disease (small vessel disease)
• You have been asked to give a brief overview of the pathogenesis of atherosclerosis to a group of high school science teachers. What would you say? Design a diagram for your presentation.