Case-based MCQ

Correct Answer Is B This patient has developed critical acute limb ischemia requiring urgent vascular surgery for revascularization and restoration of blood supply. Clinical signs of acute arterial occlusion include (6 P’s): Pain Paralysis Pulselessness Pallor Paresthesia Poikilothermia. With any of the above signs or symptoms the patient is considered to have acute limb ischemia. To confirm the diagnosis of acute arterial occlusion and the extent of obstruction, the patient should have an urgent CT angiogram as the road map to the surgery. Magnetic resonance angiography with contrast is an alternative to CT angiography with about the same sensitivity and specificity. Abdominal CT scan is not required as this patient did not present primarily with abdominal problems. Pelvic ultrasound or Doppler Duplex ultrasound of the calf veins adds nothing to the management strategy because firstly the diagnosis is already made, and secondly these modalities do not provide adequate information regarding the anatomical site of the occlusion. Furthermore , Doppler Duplex ultrasound is highly operator-dependent. Echocardiography is the investigation to consider once acute phase of arterial occlusion has been managed. Thombi from the heart is a main source of acute limb ischemia

A 40-year-old man presents to the emergency department after sudden onset of the right calf pain and paralysis. The right dorsal pedis pulse is not perceptible. The limb feels cold and is pale. The patient is given analgesics. After starting the patient on heparin , which one of the following would be the most appropriate step in management? A. Abdominal CT B. CT angiogram C. Doppler Duplex ultrasound of the calf veins D. Pelvic ultrasound E. Echocardiography

Correct Answer Is D Leg pain brought up by walking and relieved by rest and weak or absent distal pulses are characteristic of chronic limb ischemias as a result of chronic obstructive arterial disease. Atrophied muscles and shiny hairless skin supports the diagnosis. The clinical findings in chronic limb ischemia include: Weak or absent distal pulses – the hallmark finding Shiny and hyperpigmented skin Hair loss and leg ulcers Thickened nails Muscular atrophy Vascular bruits   Acute limb ischemia presents with sudden onset pain, pallor, paralysis, paresthesia, pulselessness and poikilothermia. This patient has features of chronic limb ischemia. Leg pain due to deep vein thrombosis can be brought on by walking and relieved by rest (similar to chronic limb ischemia), but other features such as sparse leg hair, pigmen tation, muscle atrophy, etc are not features of DVT. DVT presents with leg pa in and tenderness, swelling and warmth. Superficial thrombophlebitis presents with pain, erythema, induration and tenderness along the course of a superficial vein. Leg pain caused by neurogenic claudication due to spinal canal stenosis tends to get worse with erect posture and relieved by recumbency . Absence of neurological deficits makes this diagnosis less likely

A 76-year-old man comes to your office for evaluation . He mentions that he has difficulty walking because of the left leg pain. The pain is brought on after walking two blocks and gets better when he stops to rest. On examination, the leg skin is shiny and dark. The legs hair is lost and the muscles are atrophied. Distal pulses are difficult to palpate . Which one of the following is the most likely diagnosis? A. Acute limb ischemia B. Deep vein thrombosis C. Superficial vein thrombosis D. Chronic obstructive arterial disease E. Spinal canal stenosis

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Correct Answer Is B Reperfusion injury is a complication of blood restoration to a limb, which has been ischemic for a while. Characteristic features of reperfusion injury are all related to ischemia and its impacts on tissue (especially muscle cells). Features of reperfusion syndrome include: -Metabolic acidosis (lactic acidosis) -Elevated creatinine kinase -Hyperkalemia -Myoglobinemia and myoglobinuria   These findings are caused by hypoxemia resulting in metabolic acidosis, and muscle cell breakdown an d release of its cell into the blood. Hypokalemia is not a characteristic feature of reperfusion injury. The extent of the reperfusion injury depends on the following: Duration and the site of arterial blockage The extent of collateral flow to the affected area The previous health of the affected limb   Approximately one third of all deaths from arterial occlusions are due to metabolic complications after revascularisation.

A 70-year-old man presents with acute pain and paralysis of the right leg diagnosed to have been caused by acute leg ischemia. Heparin is started immediately. After emergency imaging, he is transferred to the operating room for embolectomy. Surgical intervention successfully restored blood supply to the affected limb after 3 hours. This patient is at risk of developing reperfusion injury as a result of prolonged ischemia. Which one of the following is not a characteristic feature of reperfusion injury? A. Hyperkalemia B. Hypokelemia C. Metabolic acidosis D. Myoglobinuria E. Elevate creatinine kinase

This patient presented with acute lower limb ischemia caused by femoral artery occlusion by an embolus. Signs and symptoms of acute arterial limb ischemia include pain, pallor, paraesthesia, pulselessness, paralysis and perishing cold. Paralysis or paresis and muscle compartment pain is the most ominous sign. Arterial occlusion is usually reversible if treated within 4 hours. It is often irreversible if treated after 6 hours. This patient should be given heparin 5000units intravenously and emergency embolectomy should be performed either under local or general anaesthesia. Arterial bypass is helpful if it is chronic limb ischemia. Amputation is required only if there are irreversible ischemic changes.

A 67-year-old male presented with sudden onset of left sided leg pain and paresthesias. On examination distal pulses are absent and the limb is cold. Neurological examination is normal. CT angiogram shows femoral artery embolism. What will you do next? A. Intravenous heparin infusion for 24 hours and then review B. Intravenous heparin and emergency embolectomy C. Complete bed rest until pulses are normal D. Give warfarin E. Give vitamin K

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This patient has subacute lateral elbow pain reproduced by resisted contraction of the wrist extensors, findings consistent with lateral epicondylitis (LE), sometimes referred to as lateral elbow tendinopathy.  LE is classically seen in tennis players due to repeated backhand strikes (ie, “tennis elbow”) but may occur with the use of hand tools, as in this patient, or other overuse of the wrist extensors.  Although the name implies an inflammatory process, LE is more accurately characterized as angiofibroblastic tendinosis (disorganized tissue and neovessels), and true inflammatory infiltrates are typically scant. LE primarily affects the conjoined tendon of the extensor carpi radialis brevis and extensor digitorum at the lateral epicondyle of the humerus.  Maximal pain and tenderness are typically seen approximately 1 cm distal to the lateral epicondyle, and the pain may be reproduced by passive wrist hyperflexion, resisted wrist extension, or making of a fist (eg, grip strength testing), all of which transmit force through the affected tendons. The diagnosis is usually made clinically.  Initial management involves activity modification and use of a counterforce elbow brace (tendinosis strap).  The brace is applied just distal to the elbow, reducing the load transmitted to the tendon origin.  Some patients prefer a compression sleeve. Musculoskeletal ultrasound can visualize tendon damage and assist the diagnosis of LE if the presentation is ambiguous.  X-ray is useful for suspected fractures (eg, traumatic fall) but does not visualize soft tissue (eg, tendon) injury. Short courses (eg, 1-2 weeks) of acetaminophen or low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as adjunctive treatment for pain relief in LE.  However, because LE is a degenerative rather than an inflammatory process, the benefit of NSAIDs is uncertain; high doses and extended courses are not recommended due to potential side effects (eg, gastrointestinal bleeding). Corticosteroid injection can be used for short-term pain relief in LE but does not provide long-term benefits or prevent recurrence.  It may also lead to tendon rupture.  Oral (systemic) corticosteroids are not used due to side effects (eg, hyperglycemia, immunosuppression). Surgery can be considered for patients with prolonged (ie, >6 months), severe symptoms but is rarely necessary. Lateral epicondylitis is a tendinopathy of the wrist extensors at the lateral epicondyle origin.  The pain is most severe 1 cm distal to the lateral epicondyle and is elicited by resisted wrist extension.  Initial treatment includes activity modification and use of an elbow counterforce brace.  NSAIDs are of limited value, given that the underlying pathology is chronic tendinosis rather than inflammation

A 44-year-old car mechanic comes to the office due to a 4-week history of right elbow pain.  The pain is worse when grasping tools with the right hand and is not relieved by over-the-counter nonsteroidal anti-inflammatory drugs.  He has had no acute trauma to the elbow.  On examination, the elbow is not swollen and has full range of motion.  There is tenderness on palpation around the lateral distal humerus.  Pain is reproduced when testing grip strength and with resisted wrist extension.  Which of the following is the best next step in management? A. Elbow counterforce brace B. Elbow x-ray C. High dose anti-inflammatory agent for 4 weeks D. Oral corticosteroids E. Surgical repair

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