Study Questions: Chapter 23 Chapter 23: Occupational and Environmental Disorders TERESA L. CARMAN, MD; JOHN H. FISH III, MD Study Questions: Chapter 23 * 1.) Which of the following clinical findings would be most common in a 57-year-old mechanic with suspected hypothenar hammer syndrome? Ischemic lesions of the thumb A positive reverse Allen test Vasospasm of the third digit Terminal clubbing of the digits Show answerThe correct answer is 3, Vasospasm of the third digit. Hypothenar hammer symptomatology is typically reflected in the distribution of the ulnar artery and superficial palmar arch. Ischemia or vasospastic changes are usually seen in the fourth and fifth digits. The thumb derives its blood flow from radial artery perfusion and is typically spared. The reversed Allen test assesses radial artery patency and should be normal. Terminal clubbing of the digits is most frequently reported in patients with underlying cardiopulmonary disease and has not been described in HHS. * 2.) A 20-year-old college basketball player presents with complaints of pain and itching of the lateral 3 toes of her right foot. Approximately 3 weeks prior, she attended the annual snowball rally to celebrate the end of fall semester. She admits to excess alcohol consumption during the holidays but denies use of any other drug or herbal preparations. Last year, she had similar symptoms that were not as severe and lasted until mid-January. On examination, her toes are mildly swollen and erythematous. She has no active ulcers. What is the optimal therapy to recommend at this time? Protection and cold avoidance Amlodipine, 10 mg daily Extended-release doxazosin, 4 mg every morning Topical nitroglycerin Show answerThe correct answer is 1, Protection and cold avoidance. The exposure history and symptoms are consistent with pernio. In the absence of ulceration, most patients will respond to conservative therapy of protecting the digits and avoiding ongoing cold exposure. Unlike nifedipine, amlodipine has not been studied in pernio. In addition, starting doses would be typically 2.5 mg daily. There have been no studies done with doxazosin in patients with pernio. At this time there are not enough data to suggest that topical nitroglycerin be used for treating pernio. * 3.) Which of the following characteristics suggests primary Raynaud’s syndrome? Asymmetric involvement of digits Consistent involvement of all digits, including the thumbs Angiographic findings of fixed arteriolar occlusions and corkscrew collaterals Patients may experience pallor and erythema without cyanotic changes Show answerThe correct answer is 4, Patients may experience pallor and erythema without cyanotic changes. Many patients with Raynaud’s syndrome do not describe or recognize all 3 phases of color change with their vasospastic episodes. Primary Raynaud’s is usually symmetric and thumb-sparing. Angiography is rarely warranted in primary Raynaud’s, but because the process is exclusively vasospastic in nature, there should be no abnormal angiographic findings. * 4.) A 58-year-old man is found down the day following a January football game. His core temperature is 96° F. His hands and feet demonstrate tissue injury. During rewarming, he develops significant edema and hemorrhagic bullae. What is his optimal care at this time? Debridement of the devitalized tissue Amputation of the involved extremities Protection and elevation Intravenous prostaglandin therapy Show answerThe correct answer is 3, Protection and elevation. Initial efforts at managing frostbite injury should include rapid rewarming and protection. Hemorrhagic bullae should be left intact to protect the underlying tissues until the injury is fully demarcated. Debridement and amputation should only be addressed once the extent of the tissue injury is fully known, which is usually several weeks after the injury. Adjuvant therapies including prostaglandins have not been adequately studied in patients with frostbite. * 5.) A 67-year-old motorcyclist presents with concerns regarding intermittent finger numbness and pallor while riding. He reports his hands feeling colder than normal on most days but denies tissue loss. His symptoms usually last 5 to 10 minutes after completing his ride. How would you proceed in this clinical setting? Reassure him that this is benign and no further evaluation is needed Perform antinuclear antibody testing with additional antibody testing as indicated Perform an arteriogram with provocative testing Perform digital plethysmography with thoracic outlet maneuvers Show answerThe correct answer is 2, Perform antinuclear antibody testing with additional antibody testing as indicated. His symptoms are consistent with Raynaud’s phenomenon and possibly hand vibration syndrome. Given the late age at onset, excluding secondary causes of Raynaud’s, including underlying connective tissue disorders, is prudent. Reassurance in this setting is inadequate. He should be directed to complete an evaluation and change his environment to provide protection and avoid triggers. Use of the vascular laboratory or angiography in this setting should be based on clinical examination and physical examination findings. Thoracic outlet (TO) maneuvers are unlikely to be helpful. Provocative testing during angiography is again usually limited to TO maneuvers.