Case-based MCQ

Correct Answer Is A In a patient with rheumatoid arthritis, rheumatic factor and anti-CCP antibodies are important serological markers.Rheumatoid factor positivity is associated with more aggressive disease and more extra-articular manifestations in a patient with rheumatoid arthritis. RF sensitivity is equal to anti-CCP for diagnosis of rheumatoid arthritis. However, the specificity of anti-CCP is higher. Anti-CCP is a strong predictor of erosive disease.

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Correct Answer Is A In a patient with rheumatoid arthritis, rheumatic factor and anti-CCP antibodies are important serological markers. Rheumatoid factor positivity is associated with more aggressive disease and more extra-articular manifestations in a patient with rheumatoid arthritis. RF sensitivity is equal to anti-CCP for diagnosis of rheumatoid arthritis. However, the specificity of anti-CCP is higher. Anti-CCP is a strong predictor of erosive disease.

Which of the following is true regarding Rheumatoid factor (RF) and anti-CCP in a patient with rheumatoid arthritis? A. RF positivity is associated with more aggressive disease B. RF positivity is associated with less extra-articular manifestations C. RF sensitivity is less than anti-CCP for diagnosis of rheumatoid arthritis D. Anti-CCP is a poor predictor of erosive disease E. None of the above

Correct Answer Is E The scenario is a typical description of a pseudoaneurysm as a complication of femoral artery catheterization. A pseudo aneurysm is a hematoma that forms as the result of a leaking hole in an artery. The hematoma forms outside the arterial wall and is contained by the surrounding fibromuscular tissue. The hematoma must continue to communicate with the artery to be considered a pseudoaneurysm. Pseudoaneurysm occurs in up to 7.5% of femoral artery catheterizations and can cause distal embolization, extrinsic compression on the neurovascular structures. rupture, and hemorrhage. A pseudoaneurysm presents with a painful pulsatile groin mass. A bruit over the mass may or may not be heard. Duplex Doppler ultrasound may provide evidence of extra-arterial flow or there may be classic ‘to-and-fro’ Doppler waveform in the neck of the pseudoaneurysm. Ultrasound-guided thrombin injection for the pseudoaneurysms of the iliac. femoral and peroneal arteries is safe, effective, and associated with few complications.It has emerged as the preferred treatment modality for pseudoaneurysms occurring as a result of percutaneous femoral arterial interventions (success rate: 97%). The procedure should be performed by a physician and an ultrasonographer to enable continuous visualization of the pseudoaneurysm. Thrombin is injected into the sac of the pseudoaneurysm away from the neck under direct ultrasound guidance. The ultrasound-guided compression is successful in 90% of case and was the treatment of choice previously; however, this approach is not favorable anymore because it needs prolonged compression time (up to 120 minutes). makes the patient uncomfortable,is associated with early recurrence and has limited success in treating large pseudoaneurysms. Urgent surgical exploration is indicated for a threatened limb and when a percutaneous approach is not feasible. This method was the treatment of choice before 1985. Vitamin K is not a treatment option. Any options suggesting cessation of clopidogrel is incorrect as this is associated with high mortality rate in a patient who has just undergone angioplasty. Moreover. it does not treat the aneurysm. Angiographic intervention via a retrograde approach from the contralateral common femoral artery is only indicated if acute vessel occlusion due to distal emboli occurs. The event presents with the patient complaining of pain, pallor, parenthesis or decreased movement in the respective limb. Clinical examination may reveal a cold ischemic limb with absent pulses, an ankle-brachial index (ABI) <0.5, or absent color flow and Doppler waveform on duplex ultrasound in the index artery.

A 65-year-old female patient undergoes percutaneous coronary intervention and stent placement through femoral artery, and is started on aspirin and clopidogrel. After 24 hours, she develops a pulsatile painful mass in the groin though which the catheter was sent in. Which one of the following is the definitive treatment of this mass? A. Massage and application of compression B. Surgical repair C. Vitamin K D. Angiography E. Injection of thrombin into the mass

The location of the pain and its radiation to the lower back, followed by signs of shock is consistent with a ruptured abdominal aortic aneurysm as the most likely provisional diagnosis. Before emergent transfer of the patient for surgery, vascular surgeon should be contacted, and the diagnosis should be confirmed with ultrasonography. In the meanwhile, resuscitative measures such as intravenous access, fluid administration, and supplemental oxygen should be taken in the emergency department. An ECG must be obtained pre-operatively

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A 72-year-old man comes to the emergency department complaining of epigastric pain that radiates to his lower back. While waiting for further evaluation in the emergency department, he suddenly collapses. Physical examination shows a blood pressure of 80/50 mmHg and pulse of 110 bpm. He is pale, cold and sweaty. Which one of the following is the next best step in management? A. Take the patient to the operating theatre immediately B. Arrange for CT angiography C. Non-contrast abdominal CT scan D. ECG E. Bedside ultrasonography

Correct Answer Is B This patient has the clinical features (intermittent claudication, history of smoking, obesity, and hypertension) consistent with a diagnosis of peripheral vascular disease. There are no features of critical limb ischemia (rest pain, gangrene, so this patient does not require referral to vascular surgery. This patient needs management of risks of atherosclerosis-exercise for obesity, smoking cessation and angiotensin converting enzyme inhibitor. Aspirin should not be used in patients with a peripheral vascular disease without a clinically evident cardiovascular disease. There is no reduction in vascular events in asymptomatic subjects with a low ABI randomised to daily aspirin. On top of that, looking at patient’s age and his comorbidities, usage of aspirin would possess greater risk (such as bleeding tendency) than benefit. So, the usage of aspirin is the least useful option here. Smoking cessation improves walking distance, doubles five-year survival rate and reduces the incidence of postoperative complications. Physical activity also improves walking time and walking distance. Using angiotensin-converting enzyme inhibitor, ramipril also increases pain-free walking distance and maximum walking time. Statins (HMG-CoA reductase inhibitors) are lipid lowering agents and reduces a rate of myocardial infarction, stroke and revascularization. These increase pain-free walking distance should be prescribed in all patients with the peripheral vascular disease.

A 75-year-old male with 25 pack year history of smoking developed intermittent claudication and can walk up to 200 metres now. On examination, he is obese and hypertensive.Duplex ultrasound confirms peripheral arterial disease with no critical stenosis. Which of the following options is least useful in this situation? A. Smoking cessation B. Aspirin C. Exercise D. Ramipril E. Simvastatin

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