Case-based MCQ

Correct Answer Is A Leg ulceration is typically a chronic recurring condition with duration of episodes of ulceration ranging from weeks to more than 10 years. It can cause significant distress and cost. The most common cause of lower extremity ulceration is chronic venous insufficiency due to calf muscle pump dysfunction. Compression therapy has two mechanisms of action: a static effect or resting pressure and a dynamic effect due to the changing circumference of the leg during walking. Compression increases ulcer healing rates compared with no compression. The type of compression system also has an effect on healing rate: multicomponent systems are more effective than single component systems, and those with an elastic component are more effective than those with inelastic components. Compression should not be applied before appropriate assessment and exclusion of: peripheral artery disease (e.g. ankle brachial pressure (ABPI) index <0.8) — contraindicated Appropriate assessment and management of: cardiac, renal or liver failure cellulitis acute deep vein thrombosis (once anticoagulated). Compression therapy should only be used in patients who can detect increasing pain or complications and for whom the compression system can promptly be removed (by the patient or another person). Hence, compression should be used with greater caution in patients with diabetes (peripheral neuropathy – whom might be unable to detect increasing pain). So this patient should not be prescribed any pressure stockings otherwise it can result in severe arterial insufficiency

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A 90-year-old male presents to your clinic for review of his chronic venous leg ulcers. He is keen to use compression stockings. Ankle brachial index is 0.7. What will you do next? A. Compression stockings are unsafe B. Prescribe compression stockings and refer to wound care nurse C. Give antibiotics and review in 2 weeks D. Check HbA1c E. Check fasting glucose

Correct Answer Is A The clinical and imaging findings are quite consistent with acute limb ischemia. Paralysis, paresthesia and compartment syndrome are ominous signs that demand emergency surgical intervention after heparin has been started. The golden time for surgical intervention is 4 hours. Sign s of ischemia are reversible if prompt action is taken within this period. Prolonged acute ischemia(>6 hours) leaves irreversible and permanent deficits. Heparin cover should be maintained and warfarin started.Heparin then can be safely withheld once the INR is 2-3. Warfarin alone is not recommended as it is pro-coagulation at the beginning

A 65-year-old man presents to the emergency department with sudden onset right-sided leg pain and paresthesia. On physical examination, the distal pulses of the right leg are absent and the limb is cold. A CT angiography is arranged showing thrombotic occlusion of the right femoral artery. Which one of the following is the next best step in management? A. Intravenous infusion of heparin and emergency embolectomy B. Intravenous infusion of heparin for 24 hours and review C. Complete bed rest with compression bandage and leg elevation D. Start the patient on warfarin E. Start the patient on aspirin and clopidogrel

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Correct Answer Is C This patient has signs and symptoms leading to the diagnosis of chronic obstructive arterial disease. This is characterised by intermittent claudication and often causes reproducible calf pain with activity that is relieved with rest. Examinations findings helpful in the diagnosis of the chronic obstructive arterial disease include: -Shiny, hyperpigmented skin. -Hair loss and ulceration on the legs -Thickened nails. -Muscle atrophy. -Vascular bruits. -Poor pulses are the hallmark of the chronic obstructive arterial disease. The leg pain of neurogenic claudication (spinal canal stenosis) gets worse with erect posture and is relieved by exercise. Acute limb ischemia is characterised by pain, pallor, paralysis, pulselessness, paresthesia and coldness.In deep vein thrombosis, the leg is unilaterally swollen and is characterised by pain at rest.

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A 78-year-old male came to your office for evaluation. He reported difficulty in walking long distances due to pain in the legs. He can walk up to 200 metres and then he has to stop for 5 minutes before he can continue, due to pain. Pain in legs improves after some rest.On examination, his both legs are shiny, hyperpigmented with hair loss and muscle atrophy. Distal pulses are difficult to palpate. What is the most likely diagnosis? A. Deep vein thrombosis B. Superficial thrombophlebitis C. Chronic obstructive arterial disease D. Acute limb ischemia E. Spinal canal stenosis

Correct Answer Is C The only widely accepted and validated indications for inferior vena cava filter placement in patients with thromboembolism are listed below: 1. Absolute contraindication to therapeutic anticoagulation. 2. Failure of anticoagulation when there is acute proximal venous thrombosis. This patient has already adequate anticoagulation by maintaining target INR between 2-3.However this failure of anticoagulation. Inferior vena cava filters are inserted percutaneous via a femoral or jugular approach and are usually positioned below the renal veins

A 71-year-old male presented with shortness of breath and right swollen leg two weeks after he was commenced on warfarin for pulmonary embolism after total knee replacement. His INR is 2.5. CT pulmonary angiogram shows the extension of pulmonary embolism and ultrasound of the leg shows the new onset of deep vein thrombosis. What will you do next? A. Discontinue warfarin B. Continue warfarin and consider inferior vena cava filters C. Switch warfarin to heparin, monitor APTT and consider inferior vena cava filters D. No action needed E. Give more oxygen to resolve the episode

Correct Answer Is B This patient has long-term smoking history and presented with symptoms suggestive of peripheral arterial disease. Ankle-brachial index measurement should be the first diagnostic tool used in general practice. The normal range for the ankle-brachial index is between 0.90 and 1.30. This patient should have a Duplex arterial ultrasound which is non-invasive, is useful to define sites of stenosis or occlusion, and is often the only imaging required to plan endovascular interventions. CT angiogram required contrast and this patient has a history of chronic renal failure and thus not a candidate for CT angiogram if his EGFR is low. Also, stress ECG has no role in the diagnosis of peripheral vascular disease.

A 71-year-old male presented with shortness of breath and right swollen leg two weeks after he was commenced on warfarin for pulmonary embolism after total knee replacement. His INR is 2.5. CT pulmonary angiogram shows the extension of pulmonary embolism and ultrasound of the leg shows the new onset of deep vein thrombosis. What will you do next? A. Discontinue warfarin B. Continue warfarin and consider inferior vena cava filters C. Switch warfarin to heparin, monitor APTT and consider inferior vena cava filters D. No action needed E. Give more oxygen to resolve the episode

A 76-year-old male comes to your clinic with a history of intermittent claudication. He smokes 30 cigarettes a day and drinks one drink of alcohol every night. He does have a history of chronic renal failure and hypertension. On the further assessment, it was found that his ankle-brachial index (ABI) in the right leg was 0.9 and left leg 0.25. What is the next investigation of choice? A. CT angiogram B. Duplex arterial ultrasound of lower extremities C. Fasting blood sugar D. Urine Albumin-Creatinine ratio E. Stress ECG Correct

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