EMQs in Clinical Medicine.pdf - Peshawar Medical College

Treatment of peripheral vascular disease – answers 181
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A 58-year-old person with diabetes presents with a painless punchedout
ulcer on the sole of the right foot. The surrounding area has
reduced pain sensation.
Neuropathic ulcers occur as a result of impaired sensation caused by
neurological deficit of whatever cause. Diabetes mellitus is the most
common cause of neuropathic ulcers. They are characteristically painless.
67 Treatment of peripheral vascular disease
Answers: K C I B G
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A 75-year-old smoker presents with severe rest pain in her right leg.
On examination there is advanced gangrene of the right foot with
absent pulses distal to the popliteal pulse.
It is especially important to counsel the patient adequately for such a
measure. A below-knee amputation is indicated here because there
is considerable risk of systemic infection and advancement of the
gangrene. The signs of critical limb ischaemia are sometimes summarized
as the six ‘P’s: pain, paraesthesia, pallor, pulselessness, paralysis and
perishing with cold.
A 55-year-old overweight smoker presents with pain in his legs after
walking half a mile, which is relieved immediately by rest. Ankle
brachial pressure index is 0.8.
This patient has a relatively large claudication distance (distance travelled
before he gets pain) which implies that he does not require invasive
treatment.
Ankle brachial pressure index of above 0.9 is normal. Patients with claudication
but no rest pain usually have a value that is between 0.6 and
0.9. A value below 0.6 is associated with rest pain and critical ischaemia.
Cessation of smoking, more exercise and weight reduction are useful
initial measures for the patient in this scenario.
Medical intervention includes the treatment of diabetes, hypertension
and hyperlipidaemia.
Daily low-dose aspirin is indicated.
A 62-year-old man presents with severe bilateral pain in the legs. He
is known to suffer from impotence and buttock claudication. Femoral
pulses are weak. Arteriography shows stenosis in both common iliac
arteries with good distal run-off.
The distal aorta bifurcates into the two common iliac arteries (the median
sacral branch is also given off). The common iliac artery divides to form the
external and internal iliac arteries. The external iliac artery passes under the
inguinal ligament to become the femoral artery. An aorto-bifemoral bypass
will thus provide better circulation distal to the occlusions/narrowing.