1000-2000 5 ьшò

COMMONLYASSOCIATED CONDITIONS

Foot ulcers: especially noted in diabetic patients or patients with neuropathy or vascular compromise

Infection: look for warning signs including

–Increasing size, redness, pain, or swelling

–Purulent drainage

–Fever

–Change in color of fingers or toes

Signs of gangrene (color change, coolness)

DIAGNOSIS

Most commonly a clinical diagnosis based on visualization of the lesion

Examination of footwear may also provide clues.

HISTORY

Careful history can usually pinpoint cause.

Ask about neurologic and vascular history and diabetes. These may be risk factors for progression of corns/calluses to frank ulcerations and infection.

PHYSICALEXAM

Calluses

–Thickening of skin without distinct borders

–Often on feet, hands; especially over palms of hands, soles of feet

–Colors range from white to gray-yellow, brown, red

–May be painless or tender

–May throb or burn

Corns

–Hard corns

Commonly on feet: dorsum of toes or 5th PIPjoint

Varied texture: dry, waxy, and transparent to a hornlike mass

Distinct borders

Often painful

–Soft corns

Commonly between toes, especially between 4th and 5th digits at the base of the web space

Often yellowed, macerated appearance

mebooksfree.com

Often extremely painful

DIFFERENTIALDIAGNOSIS

Plantar warts (typically a loss of skin lines within the wart), which are viral in nature

Porokeratoses (blocked sweat gland)

Underlying ulceration of skin, with or without infection (important to rule out especially with diabetic patients)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Radiographs may be warranted if no external cause is found. Look for abnormalities in foot structure, bone spurs.

Use of metallic radiographic marker and weight-bearing films often highlight the relationship between the callus and bony prominence.

Diagnostic Procedures/Other

Biopsy with microscopic evaluation in rare cases

Test Interpretation

Abnormal accumulation of keratin in epidermis, stratum corneum

TREATMENT

GENERALMEASURES

Most therapy for corns and calluses can be done as self-care in the home (1).

Use bandages, soft foam padding, or silicone sleeve over the affected area to decrease friction on the skin and promote healing with digital clavi.

Use socks or gloves regularly.

Padding to offload bony prominences

Low-heeled shoes; soft upper with deep and wide toe box

Avoidance of activities that contribute to painful lesions

Prefabricated or custom orthotics

MEDICATION

Keratolytic agents, such as urea or ammonium lactate, can be applied safely.

mebooksfree.com

Intralesional bleomycin injections have shown improvement in size and pain of warts.

In office débridement of affected tissue and use of protective padding

Use sandpaper discs or pumice stones over hard, thickened areas of skin; can be done safely at home

Geriatric Considerations

Use of salicylic acid corn plasters can cause skin breakdown and ulceration in patients with thin, atrophic skin; diabetes; and those with vascular compromise. The skin surrounding the callus will often turn white and can become quite painful. Sometimes the acids are weak enough to not penetrate the thick skin but they can burn the adjacent skin, making the condition worse. Aggressive use of pumice stones can also lead to skin breakdown, especially surrounding the callus.

ISSUES FOR REFERRAL

May benefit from referral to podiatrist if use of topical agents and shoe changes are ineffective

Abnormalities in foot structure may require surgical treatment.

Diabetic, vascular, and neuropathic patients may benefit from referral to podiatrist for regular foot exams to prevent infection or ulceration.

SURGERY/OTHER PROCEDURES

Surgical treatment to areas of protruding bone where corns and calluses form

Rebalancing of foot pressure through functional foot orthotics

Shaving or cutting off hardened area of skin using a chisel or 15-blade scalpel. For corns, remove keratin core and place pad over area during healing.

COMPLEMENTARY& ALTERNATIVE MEDICINE

May benefit from urea-based lotions, creams, or ointments

Warm water/Epsom salt soaks

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Admission usually not necessary, unless progression to ulcerated lesion with signs of severe infection, gangrene

May require aggressive débridement in operating room if an abscess or deep-

mebooksfree.com

ICD10

L84 Corns and callosities

CLINICALPEARLS

Most therapy for corns and calluses can be done as self-care in the home using padding over the affected area to decrease friction or pressure. However, if simple home care is not helpful, then removal of the lesions is often immediately curative.

mebooksfree.com

CORONARYARTERYDISEASE AND STABLE ANGINA

Adam R.S. Bainey, DO Merrill Krolick, DO, FACC, FACP, FSCAI

BASICS

DESCRIPTION

Coronary artery disease (CAD) refers to the atherosclerotic narrowing of the epicardial coronary arteries. It may manifest insidiously as angina pectoris or as an acute coronary syndrome (ACS).

Stable angina is a chest discomfort due to myocardial ischemia that occurs predictably at a certain level of exertion or emotional stress.

The spectrum of ACS includes unstable angina (UA), non–ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). See chapters on ACS for further information.

Definitions

–Typical angina: exhibits three classical characteristics: (i) substernal chest tightness, pressure, or heaviness that frequently radiates to the jaw, back, or arms and generally lasts from 2 to 15 minutes; (ii) occurs in a consistent pattern at a certain level of myocardial oxygen demand from exertion, emotional stress, or increased sympathetic tone; and (iii) relieved with rest or sublingual nitroglycerin

–Atypical angina: exhibits two of the above typical characteristics

–Noncardiac chest pain: exhibits ≤1 of the above typical characteristics

–Anginal equivalent: Patients may present without chest discomfort but with nonspecific symptoms such as dyspnea, diaphoresis, fatigue, belching, nausea, light-headedness, or indigestion that occur with exertion or stress. In patients with diabetes mellitus, women, and the elderly, one must maintain a high clinical index of suspicion as they may present with more atypical features compared with the general population.

–UA: anginal symptoms that are new or changed in character to become more frequent, more severe, or both; it is considered an ACS but does not present with cardiac biomarker elevation.

–NSTEMI: typically presents with symptoms similar to UA; however,

mebooksfree.com

cardiac biomarker elevation is noted. Ischemic ECG changes may be present, but there is no ST segment elevation.

– STEMI: presents with typical symptoms as mentioned above with ST elevations noted on ECG and elevated cardiac biomarkers; generally caused by acute plaque rupture and complete obstruction of the culprit vessel

Canadian Cardiovascular Society grading scale:

–Class I: Angina does not limit ordinary physical activity, occurring only with strenuous or prolonged exertion (7 to 8 metabolic equivalents [METs]).

–Class II: Angina causes slight limitation of ordinary activity. It occurs when walking rapidly, uphill, or >2 blocks; climbing >1 flight of stairs; or with emotional stress (5 to 6 METs).

–Class III: Angina causes marked limitation of ordinary physical activity. It occurs when walking 1 to 2 blocks or climbing one flight of stairs (3 to 4 METs).

–Class IV: Angina occurs with any physical activity and may occur at rest (1 to 2 METs).

Geriatric Considerations

Elderly may present with atypical symptoms.

Other physical limitations may delay recognition of angina until it occurs with minimal exertion or at rest.

Maintain a high degree of suspicion during evaluation of dyspnea and other nonspecific complaints.

Geriatric patients may be very sensitive to the side effects of medications used to treat angina.

EPIDEMIOLOGY

CAD is the leading cause of death for adults both in the United States and worldwide.

CAD is responsible for about 31% of all deaths and averages 1 in every 4 deaths in the United States alone.

Global cost of CAD in 2010 was $863 billion and is estimated to rise to $1,044 billion by 2030.

~80% of CAD is preventable with a healthy lifestyle.

Incidence

In the United States, the lifetime risk of a 40-year-old developing CAD is 49%

mebooksfree.com

for men and 32% for women.

Prevalence

In the United States, 28.4 million people carry a diagnosis of CAD, whereas 7.12 million have angina pectoris (1).

ETIOLOGYAND PATHOPHYSIOLOGY

Anginal symptoms occur during times of myocardial ischemia caused by a mismatch between coronary perfusion and myocardial oxygen demand.

Atherosclerotic narrowing of the coronary arteries is the most common etiology of angina, but it may also occur in those with significant aortic stenosis, pulmonary hypertension, hypertrophic cardiomyopathy, coronary spasm, or volume overload.

Sensory nerves from the heart enter the spinal cord at levels C7–T4, causing diffuse referred pain/discomfort in the associated dermatomes.

RISK FACTORS

Traditional risk factors: hypertension, ↓ HDL, ↑ LDL, smoking, diabetes, premature CAD in first-degree relatives (men <55 years old; women <65 years old), age (>45 years for men; >55 years for women)

Nontraditional risk factors: obesity, sedentary lifestyle, chronic inflammation, abnormal ankle-brachial indices, renal disease

GENERALPREVENTION

Smoking cessation

Regular aerobic exercise program

Weight loss for obese patients (goal BMI <25 kg/m2)

BPcontrol (goal <140/90 mm Hg; <150/90 mm Hg for those ≥60 years old) (2)

Diabetes management

Statin therapy for those with diabetes age 40 to 75 years and those with 10year risk ≥7.5–10% (recommendations vary)

Low-dose aspirin may be considered in those with 10-year risk ≥10% and without aspirin-use risks.

COMMONLYASSOCIATED CONDITIONS

Hyperlipidemia, peripheral vascular disease, cerebrovascular disease, hypertension, obesity, diabetes

mebooksfree.com

DIAGNOSIS

HISTORY

Careful history is important to elicit symptoms.

Pain may be described with a clenched fist over the center of the chest (Levine sign).

Discomfort is usually not affected by position or deep inspiration.

Episodes of angina are generally of the same character and in the same location.

Recent decrease in level of physical activity may be due to worsening anginal symptoms.

Dyspnea on exertion may present as the only symptom. Atypical symptoms are more likely in women, the elderly, and diabetic patients.

May present with symptoms similar to gastric reflux or GI upset (indigestion, nausea, diaphoresis)

PHYSICALEXAM

Normal physical exam does not exclude the diagnosis of angina or CAD.

Cardiac exam may reveal dysrhythmias, heart murmurs indicative of valvular disease, gallops, or signs of congestive heart failure.

Evidence of peripheral vascular disease (diminished pulses, bruits, abdominal aortic aneurysm [AAA]) may or may not be noted.

DIFFERENTIALDIAGNOSIS

Vascular: aortic dissection, pericarditis, myocarditis, myocardial infarction (MI), vasospasm

Pulmonary: pleuritis, pulmonary embolism, pneumothorax

Gastroesophageal: gastric reflux, esophageal spasm, peptic ulcer

Musculoskeletal: costochondritis, arthritis, muscle strain, rib fracture

Other: anxiety, psychosomatic, cocaine abuse

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Serial cardiac troponins to rule out MI in those presenting with prolonged pain or other symptoms compatible with ACS

CBC, lipid profile, HgbA1c (1)[C]

Basic metabolic panel to rule out electrolyte abnormalities and assess renal

mebooksfree.com

function

ECG

–Should be routinely obtained unless there is a noncardiac cause of the chest pain (1)[C]

–Frequently unremarkable between anginal episodes; may show signs of myocardial ischemia during symptomatic episodes, evidence of old MI

–Left bundle branch block or ventricular pacing makes interpretation unreliable.

Chest x-ray may exclude other causes of pain (1)[C].

Follow-Up Tests & Special Considerations

Goal is to detect possible high-risk coronary lesions where intervention would improve long-term mortality or alleviate anginal symptoms.

Stress testing is most helpful for patients at intermediate risk of heart disease.

–Exercise testing for those who can physically exercise (≥5 METs) (1)[A] Standard exercise ECG for those with normal baseline ECG

Exercise stress testing with echo or perfusion imaging for those with abnormal baseline ECG or in premenopausal women

–In patients who cannot tolerate exercise, consider pharmacologic stress

testing (1)[A].

Echocardiogram should be obtained in patients with a new or loud (≥III/VI) murmur, evidence of MI, symptoms of heart failure, concern for hypertrophic cardiomyopathy or pericardial effusion, and in those with new arrhythmias (1) [A].

Echocardiogram can be considered in patients with hypertension or diabetes and abnormal ECG (1).

CT coronary angiography or cardiac MRI can be considered as a supplement/alternative to stress testing in patients with continued symptoms despite negative stress testing, inconclusive stress testing, or need for better anatomic definition of disease (1)[A].

Diagnostic Procedures/Other

Cardiac catheterization with coronary angiography is the gold standard for confirmation and delineation of coronary disease and direction of interventional therapy or surgery. It is indicated if noninvasive testing suggests a high-risk lesion or if patient fails to respond to appropriate medical management.

Significant CAD is defined as ≥50% stenosis of the left main coronary artery

mebooksfree.com