Elderly patients with late-onset rheumatoid arthritis (RA) have more inflammation in their joints than younger RA patients, even though their overall clinical disease activity (as measured by composite scores such as the Simplified Disease Activity Index or SDAI) does not appear different.
This patient had unilateral petechiae on the dorsum of the left foot. If the petechiae were symmetric, the first condition on the differential diagnosis would be thrombocytopenia. Here, though, the platelet count was normal. The patient also had a duplex of both the arterial and venous systems that showed complete thrombosis of both the arterial AND venous systems.
The patient has a stage 1 decubitus ulcer on her left heel. Both feet are cool but are the same temperature. Distal pulses are palpable but weak on the good foot; they are not palpable on the left and can only be heard faintly with a handheld Doppler. You note unilateral petechiae on the dorsum of the left foot.
The benefits of antihypertensives in the elderly should be unquestioned—especially since SHEP and its revisit. Avoiding them will create more problems. But caution can be exercised with these specific measures.