1/11. diagnosis of intermittent vascular claudication in a patient with a diagnosis of sciatica.BACKGROUND AND PURPOSE: The purpose of this case report is to illustrate the importance of medical screening to rule out medical problems that may mimic musculoskeletal symptoms. CASE DESCRIPTION: This case report describes a woman who was referred with a diagnosis of sciatica but who had signs and symptoms consistent with vascular stenosis. The patient complained of bilateral lower-extremity weakness with her pain intensity at a minimal level in the region of the left sacroiliac joint and left buttock. She also reported numbness in her left leg after walking, sensations of cold and then heat during walking, and cramps in her right calf muscle. She did not report any leg pain. A medical screening questionnaire revealed an extensive family history of heart disease. Examination of the lumbar spine and nervous system was negative. A diminished dorsalis pedis pulse was noted on the left side. Stationary cycling in lumbar flexion reproduced the patient's complaints of lower-extremity weakness and temporarily abolished her dorsalis pedis pulse on the left side. OUTCOMES: She was referred back to her physician with a request to rule out vascular disease. The patient was subsequently diagnosed, by a vascular specialist, with a "high-grade circumferential stenosis of the distal-most aorta at its bifurcation." DISCUSSION: This case report points out the importance of a thorough history, a medical screening questionnaire, and a comprehensive examination during the evaluation process to rule out medical problems that might mimic musculoskeletal symptoms.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/11. A case of pyoderma gangrenosum on the stump of an amputated right leg.We present here a case of pyoderma gangrenosum (PG) on the stump of an amputated leg. The patient was a 69-year-old woman who had both of her legs amputated due to acute arterial occlusion. An ulcer first appeared nine years later, after which point it continued to fluctuate in size. Complications included regional blood flow disorder at the amputated stump, diabetes, and secondary infection. Despite various therapies, the ulcer exacerbated, and hypoproteinemia, increased CRP, and fever were confirmed. The patient was diagnosed as having PG based on her clinical symptoms and because the ulcer did not respond to various therapies. The ulcer improved significantly in response to administration of 40 mg/day of prednisolone, and complete epithelialization was later achieved. Given the presence of multiple complications, it was extremely difficult to confirm PG. Therefore, it is important for physicians to consider PG as one of the causes of intractable ulcers.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/11. Saint Anthony's fire revisited. Vascular problems associated with migraine medication.ergotamine and related compounds have been used for many years in the management of migraine. This review highlights the potential for toxic effects upon the arterial system which may arise from the use of ergot medications. Data on four female patients aged from 30 to 49 years were collected retrospectively from in-patient records and out-patient follow-up between 1978 and 1990. All four patients presented with the symptoms and signs of arterial obstruction and all had been prescribed ergot preparations as treatment and prophylaxis of migraine, for periods ranging from three to 12 years. Two patients had an acute arterial obstruction that resolved completely when the migraine medication was withdrawn. Two had chronic obstructions and radiological and surgical examination gave evidence of arterial stenosis. These two patients were treated with bypass surgery. review of the literature indicated that other authors had described similar cases but without specifying the methods of data collection. This report supports the findings of others regarding the toxic effects of ergot preparations upon the arterial system, which may take the form of chronic or acute obstruction. general practitioners and physicians should be aware of the possible complications arising from prolonged or excessive use of ergot medications.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/11. Laser-enhanced angioplasty.We have successfully used a balloon-guided laser to ablate arteriosclerotic plaque, thus permitting use of standard angioplasty to treat seven patients with severe peripheral artery obstruction. The device (Lastac System, marketed by G.V. Medical, Inc, and approved by FDA in December 1988) is designed to reduce the incidence of vessel perforation by using the balloon to center an argon laser between the vessel walls. A control monitor allows the physician to determine the amount and duration of energy applied. A lens on the laser tip further reduces risk of damage by narrowing the laser beam's angle of delivery, and an infusion pump cools tissue receiving laser energy and clears blood from the beam's field. Each of the seven patients treated with the Lastac System continues to be free of claudication; one patient experienced clinically insignificant vessel perforation. Although this series of patients is quite small, we believe increased use of the system will further demonstrate its effectiveness in eliminating plaque and probably will reduce the occurrence of restenosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/11. Concurrent musculoskeletal pain in a patient with symptomatic lower extremity arterial insufficiency.The etiology of back and lower extremity pain can, at times, be difficult to differentiate. This is especially true in cases where two pain-producing conditions coexist. Such difficulties have been reported in cases of coexisting vascular and neurogenic claudication. We report the case of a 66-year-old woman with concurrent musculoskeletal pain and hip claudication. Her arterial insufficiency was initially masked by her diffuse pain complaints and only became apparent to us after successful treatment of her soft tissue problems. We caution physicians to be aware of coexisting musculoskeletal pain that may mask significant underlying pathology.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/11. cerebrovascular disorders associated with pregnancy.stroke is a leading cause of maternal death. Intracerebral hemorrhage may be associated with eclampsia, metastatic choriocarcinoma or ruptured arteriovenous malformations. Intracranial venous thrombosis may result from a hypercoagulable state or local intracranial vascular damage. subarachnoid hemorrhage is usually caused by the rupture of an intracranial aneurysm or arteriovenous malformation. signs and symptoms of stroke in pregnancy can be confusing. The physician must be aware of these signs to avoid mismanagement of the pregnant stroke patient.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/11. Pulsed Doppler assessment of deep femoral artery hemodynamics: a preliminary report.The functional capability of the deep femoral artery (DFA) as a collateral channel is an important feature in patients suffering peripheral arterial occlusive disease (PAOD). A noninvasive method of indirect quantification of the DFA blood flow volume is presented. In normal lower limbs, it was found that the common femoral artery (CFA) mean blood flow volume was maintained at 59% of its resting value when the superficial femoral artery (SFA) was occluded by a pneumatic cuff placed around the thigh. The reduction of the mean flow volume is mainly due to an increase of the diastolic backward flow, while the maximum systolic flow remains constant. In a few patients with various degrees of stenosis of the DFA, we observed a much greater drop in mean CFA blood flow volume than in normal subjects. On the basis of this preliminary study, we conclude that: --When the normal SFA is occluded, pulsatile flow through the CFA is maintained. --Occlusion flow reflects the runoff and the compliance of the DFA bed. --Occlusion flow is diminished in patients with DFA stenosis. It is suggested that this non-invasive test might help the physician to assess the involvement of the DFA in PAOD. Further investigation is needed to establish the correlation between quantitative occlusion blood flow volume and the degree of DFA stenosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/11. An individualized approach to the hypertensive patient with renal disease: six illustrative case studies.One of the biggest challenges in medicine is the area of therapeutics, wherein the physician attempts to match the needs of the individual patient with a specific agent from the pharmacopeia, at the dose that might be best suited to treat the individual's problem. A great deal of the art of medicine is involved in this "matching process," in which the scientific aspects of diagnosis and therapy meet with the physician's knowledge of clinical pharmacology. The abbreviated case histories of six patients who came to the author with specific questions regarding therapy of their hypertension and renal impairment illustrate the fact that one of any number of therapies might have reduced blood pressure in these patients, but in each, there was a specific reason to attempt a single approach first. If physicians could better understand and extrapolate the results of clinical research to the treatment of specific patients, choice of therapy might become more successful.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
9/11. Interphysician agreement in the diagnosis of subtypes of acute ischemic stroke: implications for clinical trials. The TOAST Investigators.To test interphysician agreement on the diagnosis of subtype of ischemic stroke, we sent subtype definitions and 18 case summaries (clinical features and pertinent laboratory data) to 24 neurologists who have a special interest in stroke, and asked them to determine the most likely subtype diagnosis. The overall agreement was 0.64 (Kappa [K] = 0.54). Interphysician agreement was highest for the diagnoses of stroke secondary to cardioembolism (K = 0.75) or to large-artery atherosclerosis (K = 0.69). Individual physicians varied widely; four agreed with the consensus diagnosis in all 18 cases, while six others disagreed with the consensus diagnosis in three to five cases. Our level of interphysician agreement is greater than that reported in other studies and was substantial. However, despite using subtype definitions and being given extensive information often not available in the acute setting, physicians still disagree about the etiology of stroke, particularly in regard to stroke due to small-artery occlusion or of undetermined etiology. physicians seem reluctant not to attribute stroke to a specific etiology. The uncertainty about subtype diagnosis will affect interpretation of the results of clinical trials in patients selected by the subtype of ischemic stroke and also suggests that results of treatment as affected by subtype should be cautiously interpreted unless efforts to assure uniformity are included in the trial's operations. Refinement of algorithms for determining subtype of ischemic stroke do improve interphysician agreement. Such criteria should be applied strictly, and trials should include measures to assure the most uniform diagnosis of stroke subtype possible.- - - - - - - - - - ranking = 10keywords = physician (Clic here for more details about this article) |
10/11. Persistent trigeminal artery as a cause of dizziness.Complaints of vertigo and dizziness are common problems referred to otolaryngologists for evaluation. awareness of uncommon causes of dizziness increases the physician's ability to diagnose and treat these patients. We present the case of a middle-aged woman who presented with episodes of vertigo and symptoms suggestive of vertebrobasilar insufficiency. These symptoms were the result of a persistent trigeminal artery (PTA) and occlusive carotid artery disease. A PTA is a carotid-basilar anastomosis that has been reported to be demonstrated on 0.1% to 0.6% of all cerebral angiograms. Persistence of this vessel usually leads to hypoplasia or agenesis of the ipsilateral posterior communicating artery, and leaves the internal carotid artery as the main source of blood supply to the region of the upper brainstem. The appearance and clinical significance of this unusual condition will be discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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