Case-based MCQ

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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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Correct Answer Is C Superficial thrombophlebitis is a self-limiting condition which may be complicated by deep vein thrombosis or pulmonary embolism, especially in high-risk patients for venous thromboembolism. Both low molecular weight heparins (LMWH) and non-steroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of extension or recurrence of superficial thrombophlebitis by about 70% compared with placebo. For those patients who develop superficial thrombophlebitis as a complication of an intravenous infusion, consider treatment with topical or oral NSAIDs. For those patients who develop spontaneous superficial thrombophlebitis, consider treatment with low-dose low molecular weight heparins for 4 weeks and further monitoring for venous thromboembolism.

You are working in a surgical ward as a resident medical officer. You are called by a nurse to review a patient as she noticed some swelling at intravenous cannulation site on left forearm.You diagnosed the condition as superficial thrombophlebitis. What is the management? A. Reassure the patient B. Low molecular weight heparins C. Nonsteroidal anti-inflammatory drugs D. Warfarin E. Heparin infusion

Correct Answer Is E This patient has a clinical diagnosis of peripheral vascular disease. Main features of the peripheral vascular disease in this situation include intermittent claudication, rest pain and low ankle brachial index. The risk factors for the peripheral vascular disease include: – Smoking. – Hypertension. – Obesity. – Diabetes Mellitus. This patient needs a duplex ultrasound and vascular surgery referral. Duplex ultrasound is non-invasive and defines sites of stenosis or occlusion. This patient has clinical features of critical limb ischemia (rest pain) and requires revascularisation to prevent limb loss.So a referral to the vascular surgeon is critically important for possible angioplasty or endoluminal stenting.

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A middle-aged man presents with a 6-month history of pain in right calf. Pain is worsened by walking and initially relieved by rest. More recently he had rest pain in his right leg, especially at night. There is 50 pack year history of smoking. On examination, blood pressure is high, the right femoral pulse is decreased, and dorsalis pedis is not felt. Body mass index is 30. What is the most appropriate plan for management? A. Stop smoking, do exercise and follow up in 3 months B. Stop smoking, do exercise, prescribe ACE inhibitor C. Doppler venous studies and follow up in 2 weeks D. CT angiogram E. Duplex ultrasound and vascular surgery referral

Correct Answer Is B This patient has developed critical acute limb ischemia and needs urgent vascular surgery to restore the blood supply. Clinical signs of acute arterial occlusion include pain, paralysis, pulselessness, pallor, paraesthesia and poikilothermia. To confirm the diagnosis of acute arterial occlusion and extent of blockage, he needs to have urgent CT angiogram. An angiogram is the gold standard investigation which can be obtained to confirm the diagnosis, define the vascular anatomy and perfusion, and guide aggressive management.  Pelvic ultrasound and calf venous ultrasound is not helpful in making diagnosis of acute arterial occlusion. Abdominal CT scan is not required as this patient did not present primarily with abdominal problem. Echocardiogram is the investigation to be considered once acute phase of arterial occlusion has been managed.