Cardiology

Your middle-aged patientwith type 2 diabetes wishesto start a weight-trainingprogram. What recommendationswill you offerhim? Another diabetic patient hasperipheral neuropathy; which exercisesare safest for her?

A 45-year-old man presents with a 1- to2-week history of low-grade fever and nonproductivecough. He has a long history of cigarette and alcoholabuse. The office nurse expresses her concern about thepatients cyanotic nail beds and requests your immediateevaluation.

An 83-year-old woman is hospitalized for treatment of deep venous thrombosisin her left leg. She underwent left hip replacement surgery 2 months earlier.At that time, mild anemia (hemoglobin level, 10 g/dL) was noted, and iron therapywas initiated. An iron panel obtained shortly after the hip surgery revealeda serum iron level of 80 μg/dL, a transferrin level of 360 mg/dL, and a ferritinlevel of 50 ng/mL.

Lately I have heard that "tissue ACE" properties are important in endothelial remodelingand in the prevention of myocardial infarction and stroke.

My patient-an 84-year-old woman with hypertension-presented with itchingand blistering of 3 days’ duration on her right foot (Figure).

Q:Should hypertensive patients be discouraged from participating inmoderate to vigorous exercise?A:On the contrary, most patients with sustained hypertension should bestrongly encouraged to exercise regularly at moderate to vigorous levels.Randomized controlled clinical trials have demonstrated that increasedphysical activity can lower blood pressure (BP) and delay or prevent the developmentof hypertension and thus the need for antihypertensive medication.1In addition, physical activity can help reduce cardiovascular risk factors by improvinglipid profiles and reducing weight and blood glucose levels. In elderlypersons, exercise is associated with improvements in osteoporosis, depression,and physical functioning, as well as an enhanced sense of well-being.

Cataracts areone of themost importantcauses ofreversibleblindness in elderly persons.1 A recent report thatpredicts a surge in cataractincidence has heightenedawareness of the importanceof proper timing andtechniques for cataract extraction.The study, authoredby the Eye DiseasesPrevalence ResearchGroup, estimated that thenumber of Americans withcataracts will increase byapproximately 50% in thenext 20 years as the populationages.2 Cataracts werethe leading cause of low vision(less than 20/40 bestcorrected visual acuity inthe better-seeing eye)among whites, blacks, andHispanics.

Pediatric ECGs vary by age;tracings change considerablyfrom birth through adulthood.In the ECG tracing above, theT waves are inverted. Nevertheless,as we outline here, the tracingis normal in a 9-year-old child; theT waves may not revert to normaluntil he reaches puberty.

The FDA has approved injectable Acetadote (acetylcysteine)from Cumberland Pharmaceuticals Incto prevent or lessen liver damage resulting from an overdoseof acetaminophen. According to the FDA, unintentionalacetaminophen overdose is responsible for 100deaths and 56,000 emergency department visits per year.

Use this scale to easily rememberdesirable lipid levels:

Is treatment recommended for high-normalblood pressure (BP)-say, 135/88 mm Hg-ina postmenopausal woman?

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

What should be included in the optimal cardiovascular evaluation of a highschool athlete?

I have read that mental confusion and paranoia may be potential side effects ofcertain angiotensin-converting enzyme (ACE) inhibitors.

A 67-year-old man complainsof abdominal distention and bouts ofdiarrhea with intermittent constipation.These symptoms have beenpresent for weeks but recently havebecome more severe. The patienthas not seen blood in his stool. Hedenies fever, travel to a foreign country,and recent trauma. He has hypertension,which is well controlledwith calcium channel blockers.

For several weeks, a 68-year-old man has had painful blisterson his hands that crusted as they healed. The patienthas diabetes mellitus, hypertension, and chronic renalfailure, for which he is undergoing hemodialysis. His longtermmedications include a hypoglycemic agent and adiuretic.

A 62-year-old woman was found on thefloor of her bathroom at home with herwheelchair partially on top of her.She was unresponsive except to painfulstimulus.

>Editor’s note: To clearly illustrate the difference between arightward shift of axis and right axis deviation, Dr RichardHarrigan, associate professor of emergency medicine atTemple University School of Medicine in Philadelphia anda regular contributor to CONSULTANT’s “ECG Challenge”feature, provided the 3 ECGs shown here.

What is the risk of dementia in patients who have had an ischemic stroke?

A 20-year-old woman has had several episodes of syncope since she enteredcollege 2 months earlier. Although 1 or 2 episodes were associated with exercise,most were not. All occurred at times of surprise and/or emotional stress:she fainted twice when the bell rang at the end of a test, once after her alarmclock suddenly awakened her in the morning, and once when she received adisturbing phone call from home.

A 62-year-old woman presents with severe, sharp pain in her right mid chestthat worsens when she breathes. The pain began the previous night, shortlyafter she had been awakened by a shaking chill, followed by the sensationof fever. She also has a relatively nonproductive cough of recent onset.

A56-year-old woman with chest pain and emesis is brought to the hospitalby ambulance. En route, the pain resolves after nitrates, morphine,and aspirin are administered.

A 49-year-old man complains of sharp pain in the medial left ankle that begansuddenly 3 nights earlier, waking him up. That night he also felt feverish anddiaphoretic, but those symptoms have subsided. The pain is present whenhe moves the ankle or when a shoe compresses the area. No other joints areinvolved. He denies trauma to the ankle or foot.

In his Hypertension Q&A, “When Snoring Has More OminousConsequences Than a Sleepless Spouse” (CONSULTANT,October 2003, page 1410), Dr Donald Vidt suggestsseveral questions that a physician can ask patients to screenfor obstructive sleep apnea (OSA).

A number of my patients have very high high-density lipoprotein cholesterol (HDL-C)levels as well as elevated total cholesterol and low-density lipoprotein cholesterol(LDL-C) levels. One such patient is a nonsmoking middle-aged woman whose weightand blood pressure are normal.

For 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).

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.