Case-based MCQ

Correct Answer Is B Reperfusion injury is a complication of blood restoration to a limb, which has been ischemic for a while. Characteristic features of reperfusion injury are all related to ischemia and its impacts on tissue (especially muscle cells). Features of reperfusion syndrome include: -Metabolic acidosis (lactic acidosis) -Elevated creatinine kinase -Hyperkalemia -Myoglobinemia and myoglobinuria   These findings are caused by hypoxemia resulting in metabolic acidosis, and muscle cell breakdown an d release of its cell into the blood. Hypokalemia is not a characteristic feature of reperfusion injury. The extent of the reperfusion injury depends on the following: Duration and the site of arterial blockage The extent of collateral flow to the affected area The previous health of the affected limb   Approximately one third of all deaths from arterial occlusions are due to metabolic complications after revascularisation.

A 70-year-old man presents with acute pain and paralysis of the right leg diagnosed to have been caused by acute leg ischemia. Heparin is started immediately. After emergency imaging, he is transferred to the operating room for embolectomy. Surgical intervention successfully restored blood supply to the affected limb after 3 hours. This patient is at risk of developing reperfusion injury as a result of prolonged ischemia. Which one of the following is not a characteristic feature of reperfusion injury? A. Hyperkalemia B. Hypokelemia C. Metabolic acidosis D. Myoglobinuria E. Elevate creatinine kinase

This patient presented with acute lower limb ischemia caused by femoral artery occlusion by an embolus. Signs and symptoms of acute arterial limb ischemia include pain, pallor, paraesthesia, pulselessness, paralysis and perishing cold. Paralysis or paresis and muscle compartment pain is the most ominous sign. Arterial occlusion is usually reversible if treated within 4 hours. It is often irreversible if treated after 6 hours. This patient should be given heparin 5000units intravenously and emergency embolectomy should be performed either under local or general anaesthesia. Arterial bypass is helpful if it is chronic limb ischemia. Amputation is required only if there are irreversible ischemic changes.

A 67-year-old male presented with sudden onset of left sided leg pain and paresthesias. On examination distal pulses are absent and the limb is cold. Neurological examination is normal. CT angiogram shows femoral artery embolism. What will you do next? A. Intravenous heparin infusion for 24 hours and then review B. Intravenous heparin and emergency embolectomy C. Complete bed rest until pulses are normal D. Give warfarin E. Give vitamin K

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This patient has subacute lateral elbow pain reproduced by resisted contraction of the wrist extensors, findings consistent with lateral epicondylitis (LE), sometimes referred to as lateral elbow tendinopathy.  LE is classically seen in tennis players due to repeated backhand strikes (ie, “tennis elbow”) but may occur with the use of hand tools, as in this patient, or other overuse of the wrist extensors.  Although the name implies an inflammatory process, LE is more accurately characterized as angiofibroblastic tendinosis (disorganized tissue and neovessels), and true inflammatory infiltrates are typically scant. LE primarily affects the conjoined tendon of the extensor carpi radialis brevis and extensor digitorum at the lateral epicondyle of the humerus.  Maximal pain and tenderness are typically seen approximately 1 cm distal to the lateral epicondyle, and the pain may be reproduced by passive wrist hyperflexion, resisted wrist extension, or making of a fist (eg, grip strength testing), all of which transmit force through the affected tendons. The diagnosis is usually made clinically.  Initial management involves activity modification and use of a counterforce elbow brace (tendinosis strap).  The brace is applied just distal to the elbow, reducing the load transmitted to the tendon origin.  Some patients prefer a compression sleeve. Musculoskeletal ultrasound can visualize tendon damage and assist the diagnosis of LE if the presentation is ambiguous.  X-ray is useful for suspected fractures (eg, traumatic fall) but does not visualize soft tissue (eg, tendon) injury. Short courses (eg, 1-2 weeks) of acetaminophen or low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as adjunctive treatment for pain relief in LE.  However, because LE is a degenerative rather than an inflammatory process, the benefit of NSAIDs is uncertain; high doses and extended courses are not recommended due to potential side effects (eg, gastrointestinal bleeding). Corticosteroid injection can be used for short-term pain relief in LE but does not provide long-term benefits or prevent recurrence.  It may also lead to tendon rupture.  Oral (systemic) corticosteroids are not used due to side effects (eg, hyperglycemia, immunosuppression). Surgery can be considered for patients with prolonged (ie, >6 months), severe symptoms but is rarely necessary. Lateral epicondylitis is a tendinopathy of the wrist extensors at the lateral epicondyle origin.  The pain is most severe 1 cm distal to the lateral epicondyle and is elicited by resisted wrist extension.  Initial treatment includes activity modification and use of an elbow counterforce brace.  NSAIDs are of limited value, given that the underlying pathology is chronic tendinosis rather than inflammation

A 44-year-old car mechanic comes to the office due to a 4-week history of right elbow pain.  The pain is worse when grasping tools with the right hand and is not relieved by over-the-counter nonsteroidal anti-inflammatory drugs.  He has had no acute trauma to the elbow.  On examination, the elbow is not swollen and has full range of motion.  There is tenderness on palpation around the lateral distal humerus.  Pain is reproduced when testing grip strength and with resisted wrist extension.  Which of the following is the best next step in management? A. Elbow counterforce brace B. Elbow x-ray C. High dose anti-inflammatory agent for 4 weeks D. Oral corticosteroids E. Surgical repair

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