Case-based MCQ

A 40-year-old man presented with sudden onset of calf pain and paralysis of his right leg. After starting analgesia, what would be the next step in making the diagnosis? A. Abdominal CT B. CT angiogram C. Calf venous ultrasound D. Pelvic ultrasound E. Echocardiogram

Correct Answer Is E Reperfusion injury can occur in patients with acute limb ischemia when the blood supply is restored. Features of reperfusion injury include: – Acute renal failure – Hyperkalemia. – Myoglobinemia. – Metabolic acidosis. – Elevation in creatinine kinase level. Hypokalemia is not the feature of reperfusion injury. The extent of reperfusion injury depends on the duration and location of the arterial blockage, the amount of collateral flow, and the previous health of the involved limb.Approximately one-third of all deaths from the occlusive arterial disease are secondary to metabolic complications upon revascularization.

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A 62-year-old male presented with acute leg pain, paralysis and was found to have acute limb ischemia. Vascular surgery was performed which restored the blood supply by doing embolectomy within 3 hours. He is at risk of developing reperfusion injury. All of the following are features of reperfusion injury except? A. Hyperkalemia B. Metabolic acidosis C. Myoglobinemia D. Elevated creatinine kinase level E. Hypokalemia

Correct Answer Is A This patient has developed the peripheral arterial disease and chronic limb ischemia. All the patients with chronic limb ischemia should be referred to vascular surgeon for intervention when: – Rest Pain – Ischemic ulceration – Gangrene – Claudication symptoms are limiting day to life, work, and there is no improvement with exercises, risk factor modifications and medical management after six months. Revascularization is required to prevent limb loss. The surgical options include: – Endovascular angioplasty or stenting – Open surgical reconstruction by bypass or endarterectomy. The choice of the procedure will depend on the anatomic location of the occlusive disease, its extent, and the patient’s comorbidities.

Correct Answer Is A This patient has developed the peripheral arterial disease and chronic limb ischemia. All the patients with chronic limb ischemia should be referred to vascular surgeon for intervention when: – Rest Pain – Ischemic ulceration – Gangrene – Claudication symptoms are limiting day to life, work, and there is no improvement with exercises, risk factor modifications and medical management after six months. Revascularization is required to prevent limb loss. The surgical options include: – Endovascular angioplasty or stenting – Open surgical reconstruction by bypass or endarterectomy. The choice of the procedure will depend on the anatomic location of the occlusive disease, its extent, and the patient’s comorbidities.

70-year-old male presents to your office with a history of gradually worsening intermittent claudication. He has past medical history of type 2 diabetes mellitus, smoking, hypertension, hyperlipidemia and chronic limb ischemia. Which of the following sign in this patient would require surgical intervention? A. Rest pain B. Shiny skin C. Loss of hair D. Discoloured skin E. Claudication distance of 5 km

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Correct Answer Is E This patient has developed clinical features of the peripheral arterial disease (intermittent claudication, Ankle-Brachial Index less than 0.9 and decreased peripheral pulses). The management of peripheral arterial diseases crucial as it signifies the presence of generalized vascular disease. Following is the list of actions need to be taken for this patient: -Antiplatelet medication such as aspirin or clopidogrel. -Anticholesterol mediation even in the absence of dyslipidemia. -Antihypertensive medication such as ramipril or any other ACEI or ARBs. -Supervised exercise program. The beta-blockers should be avoided until and unless they are commenced for cardioprotection.

A 72-year-old male comes to your clinic with a history of left calf pain when walking to the local supermarket which is 2 kilometres away. The pain improves on resting and comes back on walking.He is a smoker and has a history of borderline hypertension. There is no history of dyslipidemia and diabetes. He is not on any regular medication. On examination, his blood pressure is 130/70. The review of the lower legs and feet is unremarkable except decreased pulse volume.The Ankle-Brachial Index is 0.8, and arterial duplex ultrasound confirms the presence of peripheral arterial disease. What of the following is the most appropriate management? A. Aspirin B. Ramipril C. Atorvastatin D. Supervised exercise program E. All of the answers stated

Correct Answer Is D This patient has non-healing diabetic foot ulcers in the presence of peripheral vascular disease. If conservative approach fails to achieve adequate healing, revascularization with angioplasty and endovascular stenting is the most appropriate option to restore the blood supply. Antihypertensive (calcium channel blockers, ACE inhibitors) and antiplatelet therapy both are not helpful in the healing of the diabetic ulcers.These should be used despite this to minimise the risk of future cardiovascular events. Antibiotics have a very limited role in chronic non-healing ulcers and are used only if the ulcers show signs of acute infection (inflammation, pus discharge, and swelling).

A 54-year-old male from the local Aboriginal community comes to your clinic for wound review. He has long-standing non-healing ulcers and conservative approach has failed to heal his wounds. Past medical history includes type 2 diabetes mellitus, hypertension, chronic renal failure and peripheral vascular disease. He smokes 60 cigarettes/day. Which ONE of the following is likely to help in wound healing? A. Calcium channel blockers B. Antiplatelet drugs C. ACE inhibitors D. Revascularization E. Antibiotics

Correct Answer Is A Enoxaparin binds to and accelerates the activity of antithrombin III.By activating antithrombin III, enoxaparin preferentially potentiates the inhibition of coagulation factors Xa and IIa. The anticoagulant effect of enoxaparin can be directly correlated to its ability to inhibit factor Xa. Factor Xa catalyses the conversion of prothrombin to thrombin, so enoxaparin’s inhibition of this process results in decreased thrombin and ultimately the prevention of fibrin clot formation. Enoxaparin does not affect APTT, international normalised ratio (INR), prothrombin time. All other options are not as helpful in DVT prophylaxis as enoxaparin.

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Mr Cosimino, a 67-year-old male is admitted to hospital with congestive cardiac failure.He has no other significant past medical history.Investigations show normal renal and liver functions, and there is no risk of bleeding. Which one of the following interventions has been demonstrated to be the most effective way of reducing the possibility of the thromboembolic event during his hospital stay? A. Enoxaparin B. Dipyridamole C. Low dose warfarin D. Aspirin E. Compression stockings

Explanation: Correct Answer Is B With intermittent calf claudication, presence of the risk factors and an ABI of 0.7 the diagnosis of chronic peripheral arterial disease is almost established. Management of peripheral arterial disease includes the following: Smoking cessation · smoking is the most important predisposing factor for peripheral arterial disease(PAD). Smoking cesation alone is associated with an improvement in the distance of pain-free walk, doubled 5-year survival and better post-op outcomes. Exercise – exercise on an as tolerated basis. improves the pain-free walking distance and time and should be advised for all patients. ACE inhibitors – evidence suggests that ACE inhibitors may improve walking ability in patients with intermittent claudication. The ACE inhibitor with greatest evidence of benefit is ramipril. It is unknown if the improvement in walking distance associated with ramipril is due to a class effect of ACE inhibitors or whether it is specific to this medicine. The ABI does not seem to imp roved though. Statins – statins improve revascularisation. pain-free walking distance and survival. Of all lipid-lowering agents. only statins have been proved to lower the mortality in patients with vascular diseases due to atherosclerotic changes.It should be started for patients with coronary artery disease,PAD. aortic disease (e.g. abdominal aortic aneurysm),carotid artery disease and diabetes mellitus. Clopidogrel and aspirin – they are often prescribed to reduce the overall risk of myocardial infarction and stroke, but are not associated wit h improvement of PAD symptoms. Beta blockers (e.g. metoprolol) are not indicated in the absence of cardiac disease. They have no effect on PAD. The goals of PAD management are to: decrease the occurrence of cardiovascular events and prevent death reduce limb symptoms, improve exercise capacity, and thus improve quality of life prevent or lessen disability and progression to limb loss. These goals can be attained through a comprehensive treatment program, which includes lifestyle modifications, exercise and diet, and pharmacotherapy for all PAD patients; and invasive revascularisation for patients with limiting claudication or critical limb ischaemia (CLI). Patients should be referred to a vascular surgeon when: - the diagnosis is uncertain - Critical Limb Ischemia (CLI) is evident by rest pain, ischaemic ulceration, or gangrene - claudication symptoms limit work or lifestyle, and there has been no improvement with an exercise program, risk factor modification and medical management after a 4–6 month period - consideration of interventional management is felt appropriate by the patient and the general practitioner. Patients with CLI (rest pain, tissue loss, or gangrene) usually require revascularisation to prevent limb loss. Patients with lifestyle limiting symptoms that do not improve with medical management should also be considered for intervention. The main options include endovascular angioplasty or stenting, or open surgical reconstruction by peripheral bypass or endarterectomy. The choice of procedure will depend on the anatomic location of the stenotic/occlusive disease, its extent, and the patient’s comorbidities. Among the given option, smoking cessation, statins and ACE inhibitors are the best possible management and the advice for this patient.

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