Case-based MCQ

⏳ Case-based MCQ | #Case_458 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 41-year-old man presents to the ED with acute onset of a right-sided facial droop. He cannot close his right eye, and he also cannot move the right side of his face when asked to smile. He does admit that he had an upper respiratory infection recently. His speech is not impaired and he has normal motor and sensory exam of his extremities on both sides. His head CT is also normal.

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⏳ Case-based MCQ | #Case_458 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B This patient presents with the triad of lower extremity edema, cyanosis, severe pain after 24 hours of experiencing blanching and edema; this is suggestive of the diagnosis of phlegmasia cerulea dolens (PCD), which usually follows phlegmasia alba dolens. This is a rare complication of massive deep vein thrombosis (DVT) that presents suddenly with complete venous occlusion leading to impaired arterial flow. Often the iliofemoral area is affected, and the impaired drainage disorder results in tissue ischemia. This serious condition can lead to venous gangrene of the extremity and compartment syndrome. It is an emergency that requires prompt diagnosis and effective treatment as the mortality rate is between 25% and 40%, while the risk of amputation could be as high as 50%. The most significant risk factors are malignancy, such as breast cancer (choice B), heart failure, heparin-induced thrombocytopenia, surgery, trauma, and third-trimester pregnancy. ⚠ Atherosclerosis (choice A) is the underlying disease in peripheral arterial disease, which could also lead to decreased dorsalis pedis pulse, but this patient's clinical presentation strongly suggests PCD. ⚠ Diabetes mellitus (choice C) is a risk factor for atherosclerosis, which could lead to decreased lower extremity arterial pulses, but it is not significantly associated with PCD. ⚠ Hyperthyroidism (choice D) is not a risk factor for DVT or PCD. ⚠ Thromboangiitis obliterans (choice E), also known as Buerger's disease, is a vasculitis affecting the lower extremities that has been associated with smoking. Pain, cyanosis, gangrene can all occur, making it similar to the PCD. Patients are usually younger than 45 years, and the blanching that preceded the patient's current condition steers us towards phlegmasia. 🔖 Key point: A triad of lower extremity edema, cyanosis, severe pain after 24 hours of experiencing blanching and edema is suggestive of the diagnosis of phlegmasia cerulea dolens, a rare complication of massive deep vein thrombosis that presents suddenly with complete venous occlusion leading to impaired arterial flow.

⏳ Case-based MCQ | #Case_458 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 54-year-old female presents to your department with complaints that the left leg has just turned blue, is swollen, and in severe pain. Even though the symptoms became worse an hour ago, 24 hours earlier, she had noticed that the skin of her left leg had whitened and was a bit swollen, she had tried to use compression stockings, but they had not helped. Her past medical history is significant for stasis ulcers, for which compression stocking had been helpful. On physical examination, left leg edema and cyanosis are noted. The dorsalis pedis pulse is significantly decreased.

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