What is the best management approach for a patient with a growing lesion on the left forearm, bilateral ankle swelling, and shoulder pain, who also has pre-diabetes, dyslipidaemia, and hypertension, and works outdoors as a painter?

Management Approach for Growing Forearm Lesion, Bilateral Ankle Swelling, and Shoulder Pain in a Pre-Diabetic Painter

This patient requires urgent dermatological evaluation with excisional biopsy of the forearm lesion given the concerning features of growth, sun exposure history, and raised morphology, while simultaneously initiating aggressive cardiovascular risk factor modification including high-intensity statin therapy for dyslipidaemia and comprehensive peripheral arterial disease screening given the bilateral ankle edema in the context of pre-diabetes.

Forearm Lesion Management

The growing, raised lesion on sun-exposed skin in an outdoor worker with significant UV exposure history warrants immediate dermatology referral for excisional biopsy to exclude melanoma or other skin malignancies. Key concerning features include:

• Progressive size increase over one year in a sun-exposed area
• Raised morphology suggesting possible malignant transformation
• Occupational outdoor sun exposure as a painter increases cumulative UV damage risk

The lesion should be photographed, measured precisely, and referred within 2 weeks for specialist evaluation. Do not delay referral for "watchful waiting" given the growth pattern.

Bilateral Ankle Edema Evaluation

The bilateral pitting edema requires systematic evaluation for peripheral arterial disease (PAD), venous insufficiency, and cardiac causes, with PAD screening being critical given this patient's pre-diabetic status. 1

Immediate Diagnostic Workup:

• Ankle-brachial index (ABI) measurement bilaterally - An ABI <0.9 indicates PAD, though values >1.40 may reflect arterial calcification common in pre-diabetes and require alternative testing 1
• Comprehensive pulse examination including femoral, popliteal, dorsalis pedis, and posterior tibial arteries bilaterally 1
• Inspection for signs of arterial insufficiency including dependent rubor, pallor on elevation, delayed capillary refill, hair loss, and dystrophic toenails 1
• Echocardiogram to assess for heart failure given mild exertional dyspnea, though normal cardiovascular examination makes this less likely

PAD Screening Rationale:

Pre-diabetic patients require annual PAD screening as they have 2-4 fold increased risk of lower extremity arterial disease (LEAD), with 16% of adults aged 35-54 years showing diminished dorsalis pedis pulsation 1, 2. Early diagnosis is critical because:

• Mortality is significantly increased in patients with LEAD, with three-year survival after amputation less than 50% 1
• Pre-diabetes duration and severity influence gangrene and ulceration risk 1, 2
• The patient's occupational ladder work may mask claudication symptoms

If ABI is abnormal (<0.9) or falsely elevated (>1.40 due to calcification), proceed to duplex ultrasound of lower extremities to assess arterial anatomy and hemodynamics 3. Post-exercise ABI may identify significant LEAD even with normal resting values 1.

Alternative Causes to Consider:

• Venous insufficiency from prolonged standing on ladders - examine for varicosities, skin changes, and venous reflux
• Occupational dependent edema - though the acute onset and pitting nature suggest more than simple dependency
• Medication-induced edema - though patient reports taking no medications

Cardiovascular Risk Factor Management

Initiate high-intensity statin therapy immediately to achieve LDL-C <1.4 mmol/L (55 mg/dL) with >50% reduction from baseline, given the patient's very high cardiovascular risk profile. 4

Lipid Management Algorithm:

1. Start atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily as first-line high-intensity statin 4
2. Add ezetimibe 10 mg daily if LDL-C target not achieved after 4-6 weeks on maximally tolerated statin 4
3. Consider PCSK9 inhibitor if targets still not met after statin plus ezetimibe 4

The patient's lipid profile shows:

• Elevated total cholesterol and triglycerides
• Low HDL cholesterol
• This dyslipidaemia pattern is characteristic of pre-diabetes and significantly increases cardiovascular risk 5, 6

Blood Pressure Management:

Target blood pressure <130/80 mmHg using ACE inhibitor or ARB as first-line therapy. 4

• ACE inhibitors/ARBs reduce cardiovascular events and protect renal function in pre-diabetic patients 4, 7
• Add thiazide diuretic as second-line if target not achieved 4
• Caution: Monitor for worsening ankle edema with calcium channel blockers if added later

Glycemic Control:

Initiate metformin therapy for pre-diabetes management given HbA1c in pre-diabetic range, elevated cardiovascular risk, and dyslipidaemia. 4

• Metformin is the cornerstone of treatment with established cardiovascular benefits 4
• Target HbA1c <7% while avoiding hypoglycemia 4
• Consider adding SGLT2 inhibitor with cardiovascular benefit if progression to diabetes occurs 4

Antiplatelet Therapy:

Do not initiate aspirin for primary prevention at this stage - reserve for secondary prevention if PAD or other atherosclerotic cardiovascular disease is confirmed 4

Shoulder Pain Management

The shoulder pain is likely occupational (painting-related repetitive strain) and should be managed conservatively with:

• NSAIDs for pain control (short-term, monitoring renal function)
• Physical therapy referral for rotator cuff strengthening
• Ergonomic assessment of painting technique
• Consider orthopedic referral if conservative management fails after 6-8 weeks

Lifestyle Modifications

Implement aggressive lifestyle changes as foundation of cardiovascular risk reduction: 4

• Smoking cessation reinforcement - the patient is an ex-smoker; ensure no relapse given occupational stress
• Mediterranean or DASH diet with reduced saturated fats, increased omega-3 fatty acids, and plant stanols 4
• Weight loss goal of 5-10% body weight through caloric restriction given recent weight gain 4
• Regular physical activity: 30-60 minutes moderate-intensity exercise most days - may need modification based on shoulder pain 4
• Sun protection counseling given outdoor occupation and skin lesion history

Follow-Up Schedule

Structured monitoring is essential to prevent progression to diabetes and cardiovascular complications:

• 2-week dermatology referral for forearm lesion biopsy
• 4-week follow-up for ABI results, lipid panel on statin therapy, blood pressure check, and metformin tolerance
• 3-month intervals for glycemic control (HbA1c), lipid parameters, and blood pressure monitoring until targets achieved 4
• Annual comprehensive PAD screening including pulse examination and ABI 1, 2
• Annual screening for diabetic complications including nephropathy (urine ACR), retinopathy, and neuropathy 4

Critical Pitfalls to Avoid

Common errors that worsen morbidity and mortality in this population:

• Delaying skin lesion evaluation - melanoma prognosis is stage-dependent; early excision is curative [@general medical knowledge@]
• Attributing ankle edema solely to occupational dependency without PAD screening - missing PAD in pre-diabetic patients leads to preventable amputations 1, 2
• Underestimating cardiovascular risk - pre-diabetes with dyslipidaemia and hypertension constitutes very high cardiovascular risk requiring aggressive intervention 4, 6
• Using beta-blockers for hypertension as first-line - while not contraindicated in PAD, ACE inhibitors/ARBs are superior for renal protection and cardiovascular outcomes in pre-diabetes 1, 4
• Failing to monitor for medication interactions between antihypertensives, statins, and potential future glucose-lowering agents 4
• Ignoring occupational factors - prolonged ladder work and sun exposure require specific counseling and protective measures

Watch for heart failure symptoms as patients with pre-diabetes and cardiovascular risk factors have increased heart failure risk, especially if SGLT2 inhibitors are added later 4.