Case-based MCQ

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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.

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