A 78-year-old retired professor comes to the physician because of occasional headaches that have gradually worsened over the last six months. The headaches are right-sided and involve the corner of the right eye. He also gets pains in his jaw while chewing food. He has hyperlipidemia and he takes atorvastatin daily. He asks if the medication might be causing his symptoms.
His other medical problems include coronary artery disease for which he had a stent placed in his left anterior descending artery five years ago. He has no history of strokes, vision problems, or peripheral artery disease. He is a lifetime non-smoker.
Physical examination reveals a right-sided carotid bruit. Heart sounds are normal. The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

Which of the following should be part of the long-term management for this patient?

Question

A 78-year-old retired professor comes to the physician because of occasional headaches that have gradually worsened over the last six months. The headaches are right-sided and involve the corner of the right eye. He also gets pains in his jaw while chewing food. He has hyperlipidemia and he takes atorvastatin daily. He asks if the medication might be causing his symptoms.
His other medical problems include coronary artery disease for which he had a stent placed in his left anterior descending artery five years ago. He has no history of strokes, vision problems, or peripheral artery disease. He is a lifetime non-smoker.
Physical examination reveals a right-sided carotid bruit. Heart sounds are normal. The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

Which of the following should be part of the long-term management for this patient?

Quizplus · Accepted Answer

11ec193a_9915_c1d9_853d_150c361f2b82_MD0002_00 This patient's presentation (i.e., jaw claudication, new headache, and increased ESR) is most consistent with giant cell arteritis (GCA). Although there are many nonspecific findings in GCA (summarized in the above table), jaw claudication is the most specific symptom and is seen in up to 50% of cases. Laboratory findings include elevated ESR, elevated C-reactive protein, and a normocytic normochromic anemia. Temporal artery biopsy confirms clinical diagnosis and treatment involves immediate glucocorticoid therapy. Since GCA affects primarily postmenopausal women and older men, steroids can predispose or worsen pre-existing osteoporosis. As a result, all patients should undergo bone mineral density measurements. Patients with GCA receiving steroids should also receive adjunctive calcium, vitamin D, and possibly bisphosphonates. (Choice A) Although steroid therapy may predispose to ulcers, eradication of H. pylori does not significantly affect this. (Choice B) Statin myopathy usually presents with proximal muscle myalgias/weakness (sometimes with elevated CK), but is usually not associated with jaw pain. (Choice D) Screening for abdominal aortic aneurysms is less beneficial since they are much less common than ascending aortic aneurysms in GCA patients. It is recommended to perform yearly chest x-rays (up to ten years) to identify patients with thoracic aortic aneurysms prior to rupture or dissection. (Choice E) Vitamin B₁₂ deficiency usually causes a macrocytic anemia. However, GCA is usually associated with a normochromic normocytic anemia and reactive thrombocytosis that improves with steroids. ₁₂ Educational objective: Patients with giant cell arteritis can present with nonspecific symptoms (i.e., fever, fatigue, and weight loss), but jaw claudication is the most specific symptom. Temporal artery biopsy confirms the diagnosis, and prompt treatment with glucocorticoids should be initiated. All patients should undergo osteoporosis screening when starting steroids and yearly chest x-rays (up to ten years) to identify patients with thoracic aortic aneurysms. __________ References: Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management. (http://www.ncbi.nlm.nih.gov/pubmed/21812500)

A 78-Year-Old Retired Professor Comes to the Physician Because of Occasional