Download Question 1 : SC

Case 598: MCQs in vascular surgery - 1
Authors and Affiliations
Peter Devitt
Department of Surgery
University of Adelaide
Case Overview
These MCQs are suitable for those studying for end-of-year examinations.
Learning Objectives
.
Question 1 : SC
Question Information:
A 72-year-old man presents for routine follow up of hypertension and hyperlidaemia. He is well and has
no other significant medical history. He takes perindopril, simvastatin and aspirin. He drinks 15 gm
alcohol/day and stopped smoking 20 years ago. His BMI is 28, blood pressure is 145/86 mmHg and
pulse 74/min and regular. The cardiac examination is normal and a systolic bruit is heard over the right
common carotid artery. Duplex ultrasonography confirms the presence of a 70% stenosis on the right
and a 20% on the left.
Question:
Which one of the following is the most appropriate management?
Choice 1: Right carotid stent Score : 0
Choice Feedback:
Incorrect.
Choice 2: Bilateral carotid stenting Score : 0
Choice Feedback:
Incorrect.
Choice 3: Bilateral carotid endarterectomy Score : 0
Choice Feedback:
Incorrect.
Choice 4: Right sided carotid endarterectomy Score : 0
Choice Feedback:
Incorrect.
Choice 5: Lose weight and continue conservative management Score : 1
Choice Feedback:
Correct. Based on recent evidence, opinions have recently changed on the long-term management of
the patient with an asymptomatic carotid bruit. Two studies published in the late 1990s suggested that
the annual stroke rate in patients with asymptomatic carotid bruits could be reduced by carotid
endarterectomy. With recent improvements in medical therapy and identification of high risk subgroups
(eg plaque changes seen on ultrasound), it is apparent than appropriate medical management is better
than surgical intervention.
Question 2 : SC
Question Information:
A 68-year-old man presents with a three week history of early morning headaches. He has a 40 packyear smoking history and three months ago was assessed for symptoms of intermittent claudication. At
that time his blood pressure for 130/86 mmHg and he was advised to stop smoking and given a graded
exercise program. His blood pressure is now 168/100 mmmHg and an abdominal bruit can be heard in
the supra-umbilical region. His serum creatinine is 0.15 mmol/L (0.05-0.12).
Question:
Which one of the following is the most appropriate initial investigation?
Choice 1: Captopril renal scintigraphy Score : 0
Choice Feedback:
Incorrect.
Choice 2: Doppler ultrasonography Score : 1
Choice Feedback:
Correct. This is the simplest of the non-invasive investigations. Doppler ultrasonography will provide
information on the anatomical appearances of the renal vasculature and the characteristics of flow. This
tool can predict which individuals with renal artery stenosis are likely to respond to intervention. CT or
MR angiography are useful non-invasive imaging tools, but should not be used in this instance where
there is impaired renal function. Captopril studies lack the required specificity and sensitivity and have
been replaced by the other imaging tools listed in this question. The definitive investigation is
conventional renal angiography, but this is invasive and is not the first-line imaging modality.
Choice 3: Gadolinium-enhanced MR angiography Score : 0
Choice Feedback:
Incorrect.
Choice 4: CT angiography Score : 0
Choice Feedback:
Incorrect.
Choice 5: Intra-arterial digital subtraction angiography Score : 0
Choice Feedback:
Incorrect.
Question 3 : SC
Question Information:
A 65-year-old woman is being assessed at a pre-admission clinic in preparation for a right knee
arthroplasty. Her medical history includes glaucoma for which she takes timolol and a myocardial
infarction and stent insertion one year ago for which she is on aspirin and clopidogrel. She had a deep
vein thrombosis five years ago and had varicose veins during her two pregnancies.
Question:
Which one of the following poses the greatest risk for a further venous thromboembolic event?
Choice 1: The myocardial infarction Score : 0
Choice Feedback:
Incorrect.
Choice 2: Varicose veins in pregnancy Score : 0
Choice Feedback:
Incorrect.
Choice 3: Glaucoma Score : 0
Choice Feedback:
Incorrect.
Choice 4: Presence of the stent Score : 0
Choice Feedback:
Incorrect.
Choice 5: The previous deep venous thrombosis Score : 1
Choice Feedback:
Correct. This patient has a number of potential risk factors for VTE, of which the history of DVT poses
the greatest risk. Current varicose veins might also increase the risk of VTE, but less so the existence
of varicosities during pregnancy alone. Acute myocardial infarction is an important risk factor - but this
patient's infarction was 12 months early and will pose less of a risk factor than the recent DVT.
Question 4 : SC
Question Information:
A 57-year-old man presents with a two-month history of aching in his right calf, the symptoms appearing
when he walks more than 200 metres. When he stops and rests the pain goes away. He has a 30 packyear smoking history and has type 2 diabetes. His lower limb pulses are all palpable, with an ankle
brachial index of 0.9 on the left and 0.8 on the right.
Question:
Which one of the following is the most appropriate next step in management?
Choice 1: Doppler ultrasonography Score : 1
Choice Feedback:
Correct. At this stage all the patient needs is a non-invasive assessment to look for any stenotic
segments in his lower limb vascular tree. He does not have a threatened limb and invasive
investigations are not required.
Choice 2: CT angiography Score : 0
Choice Feedback:
Incorrect.
Choice 3: MR angiography Score : 0
Choice Feedback:
Incorrect.
Choice 4: Transfemoral angiography Score : 0
Choice Feedback:
Incorrect.
Choice 5: Digital subtraction angiogram Score : 0
Choice Feedback:
Incorrect.
Question 5 : SC
Question Information:
A 74-year-old man is brought to the Emergency Department having collapsed at home with severe,
generalised abdominal pain. The patient is known to have hypertension and had a myocardial infarction
six years previously. On examination his blood pressure is 62/44 mmHg and pulse rate 124/min. There
is a pulsatile mass in his mid-abdomen. He is rapidly given one litre of intravenous colloid solution and
his blood pressure changes to 70/48 mmHg.
Question:
Which one of the following is the most appropriate next step in management?
Choice 1: CT abdomen Score : 0
Choice Feedback:
Incorrect.
Choice 2: Chest X-ray Score : 0
Choice Feedback:
Incorrect.
Choice 3: Ultrasound abdomen Score : 0
Choice Feedback:
Incorrect.
Choice 4: Laparotomy Score : 1
Choice Feedback:
Correct. This patient almost certainly has a ruptured abdominal aortic aneurysm. The mortality rate is
high and if he is to stand any chance of survival the patient must be taken straight to the operating
room. Any delay is likely to have fatal consequences. A haemodynamically stable patient might be
considered for some form of imaging - but not in these circumstances.
Choice 5: Aortic balloon pump Score : 0
Choice Feedback:
Incorrect.
Question 6 : SC
Question Information:
A 56-year-old man presents with increasing pain in his right calf, worsened by exercise. Over the last
two weeks the pain has been constantly present and is disturbing his sleep. He smokes 30 cigarettes a
day and takes perindopril for hypertension. On examination his right femoral pulse is diminished in
volume and the distal pulses in the right leg are not palpable. The ankle-brachial index is 0.2.
Question:
Which one of the following is the most appropriate next step in management?
Choice 1: Advice on smoking cessation Score : 0
Choice Feedback:
Incorrect.
Choice 2: Graduated exercise program Score : 0
Choice Feedback:
Incorrect.
Choice 3: Doppler studies Score : 0
Choice Feedback:
Incorrect.
Choice 4: Pentoxifylline Score : 0
Choice Feedback:
Incorrect.
Choice 5: CT angiogram Score : 1
Choice Feedback:
Correct. This man has critical, limb-threatening ischaemia. The change from intermittent to constant
pain is an index of the severity of the occlusive process and the patient now needs some form of active
intervention. An ankle-brachial ratio of less than 0.3 is indicative of critical ischaemia. As a prelude, he
will need some sort of imaging to define the site, length and degree of occlusion. The most effective
means will be a CT angiogram. Arguments could be made for MR angiography if the vessels were
heavily calcified, or going directly to percutaneous angiography if some form of stenting or balloon
angioplasty was thought appropriate.
Question 7 : SC
Question Information:
A 73-year-old man presents after two episodes of severe mid-abdominal pain over the previous 24
hours. The pain radiated though to his back and during each episode he felt pale and sweaty. On both
occasions the symptoms resolved after a few hours. He has not passed urine for 12 hours.
Question:
Which one of the following is the most likely diagnosis?
Choice 1: Acute retention of urine Score : 0
Choice Feedback:
Incorrect.
Choice 2: Ureteric colic Score : 0
Choice Feedback:
Incorrect.
Choice 3: Acute pancreatitis Score : 0
Choice Feedback:
Incorrect.
Choice 4: Leaking aortic aneurysm Score : 1
Choice Feedback:
Correct.
Choice 5: Mesenteric vascular occlusion Score : 0
Choice Feedback:
Incorrect.
Question 8 : SC
Question Information:
A 74-year-old man presents with a two week history of pain in his right foot. This is worse at night and
relieved by dangling his foot over the edge of the bed. Prior to this his symptoms of right calf pain,
aggravated by walking, had been getting worse.
Question:
The presence of which one of the following is most suggestive of the need for urgent investigation and
treatment?
Choice 1: Venous guttering on elevation of the affected leg Score : 0
Choice Feedback:
Incorrect.
Choice 2: Coolness of the affected limb Score : 0
Choice Feedback:
Incorrect.
Choice 3: Diminished sensation on the sole of the right foot Score : 0
Choice Feedback:
Incorrect.
Choice 4: A dusky blue colour to the right foot Score : 0
Choice Feedback:
Incorrect.
Choice 5: Inability to move his toes of the right foot Score : 1
Choice Feedback:
Correct.
Question 9 : SC
Question Information:
A 64-year-old man presents to his general practitioner with a six month history of pain in his right calf.
The pain comes on when he walks about 200 metres and gradually goes away when he rests. These
symptoms have been getting worse over the last two weeks. He also has type II diabetes and had a
myocardial infarction two years ago.
Question:
Which one of the following features would suggest the need for some form of surgical intervention?
Choice 1: Rest pain Score : 1
Choice Feedback:
Correct. The presence of rest pain is the cardinal symptom in the assessment of severity of peripheral
vascular disease. Whilst intermittent symptoms can be treated by conservative means, once the
patient's symptoms persist and occur at rest, prompt referral for a surgical opinion is essential. This
patient will require some form or revascularisation if his limb is to be saved.
Choice 2: Loss of sensation to the foot Score : 0
Choice Feedback:
Incorrect.
Choice 3: Absent right femoral pulse Score : 0
Choice Feedback:
Incorrect.
Choice 4: An ankle-brachial index of 0.7 Score : 0
Choice Feedback:
Incorrect. This is not the critical level. A ratio of less than 0.5 suggests severe arterial insufficient and
the need for imaging and consideration of some form of intervention to improve the distal blood supply.
Choice 5: Symptoms developing in the other leg Score : 0
Choice Feedback:
Incorrect.
Question 10 : SC
Question Information:
A 70-year-old man is found to have a soft right-sided carotid bruit during assessment of intermittent
claudication. The finding appears to be incidental. He does not take any medications. Apart from absent
pulses in his left leg, there are no other abnormal physical findings.
Question:
Which one of the following is the most appropriate initial investigation?
Choice 1: Doppler ultrasonography Score : 1
Choice Feedback:
Correct. Depending on the degree of stenosis and the morphology of the stenotic segment, the patient
may need active medical medical - such as dual anti-platelet therapy.
Choice 2: CT angiography Score : 0
Choice Feedback:
Incorrect.
Choice 3: Echocardiography Score : 0
Choice Feedback:
Incorrect.
Choice 4: Electrocardiogram Score : 0
Choice Feedback:
Incorrect.
Choice 5: Lipid profile Score : 0
Choice Feedback:
Incorrect.
Question 11 : SC
Question Information:
543 Q.3. A 63-year-old woman presents with a painless ulcer on the plantar aspect of her right foot.
This has been present for several weeks and shows no evidence of healing. She has a six month
history of pain in her right calf when comes on when she walks about 200 metres and settles when she
rests. She has type II diabetes and hypertension.
Question:
Which one of the following physical signs is most likely to be present?
Question 12 : SC
Question Information:
543 Q.7. A 65 year old physically active diabetic presents with a neuropathic ulcer.
Question:
Where is the ulcer most likely to be situated?
Synopsis
Nil