Medical Differential Diagnosis Practice Case #3 (Leg Pain)
Medical Differential Diagnosis Practice Case #3 (Leg Pain)
The following case is meant to function as a practice case for students within medicine, neurology, chiropractic, osteopathy or similar healthcare professions which are involved in diagnosing medical and neurological pathology.
Be forewarned that the answers to the case is listed at the bottom of this article. Good luck!
Case:
A 70 yoa male complains of increasing pain in his left calf muscle over the last 9 months. He cannot remember how the pain started, but he only noticed it whilst climbing stairs or walking uphill for long distances. The pain has gradually worsened and is now present even when walking on the flat. He describes the pain as ‘cramping’ and mild (2/10 NRS) when it begins, but it rapidly worsens if he continues to walk (8/10 NRS), however, the pain is quickly relieved by resting a minute or two.
Recently he has noticed an occasional dull ache in the calf even when sitting. He suffered from angina for many years, but, following a mild myocardial infarction 4 years ago, he has not had the same chest pain unless he ‘pushes himself’ or becomes very ‘upset’.
He used to smoke 30/day until his MI 4 years ago when he stopped. He drinks 4 units of alcohol per day. He takes low-dose aspirin daily and was prescribed a statin medication after his MI, but has stopped taking them recently because they upset his digestion.
On examination his heart rate is 86 BPM, temperature 37.2⁰C and BP 152/88 mmHg. His BMI is 26.2. Cardiovascular examination is unremarkable except for a bruit over the right carotid vessel. Both femoral pulses are present, but the left popliteal and pedal pulses are absent. The ankle-brachial pulse index (ABPI) is 0.6 on the left and 0.8 on the right.
Q. 1 – What is the most likely diagnosis?
A. Thrombophlebitis
B. Chronic Compartment Syndrome
C. Deep Vein Thrombosis
D. Acute Arterial Occlusion
E. Intermittent Claudication
Q. 2 – What further physical examination procedure should you perform?
A. Abdominal Examination
B. Allen’s Test
C. Vibration Testing
D. Extensor Plantar Reflex
E. Valsalva Manoeuvre
Q.3 – Which supplementary investigation would best help establish the diagnosis?
A. Lumbo-pelvic X-ray series
B. Serum Lipid Profile
C. Full Blood Count
D. Doppler Ultrasound
E. Glucose Tolerance Test
Q.4 – The rationale for the administration of aspiriin therapy, for this patient, is based on which of aspirin’s pharmaceutical effects?
A. Anti-pyretic effect
B. Analgesic effect
C. Anti-platelet effect
D. Anti-neoplastic effect
E. Anti-alzheimer’s effect
Q.5 – The ankle-brachial index associated with rest pain is considered to be?
A. <0.9
B. <0.8
C. <0.7
D. <0.6
E. <0.5
-- Warning: List of answers to the cases follows below this text. –
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Answers:
Q. 1 – What is the most likely diagnosis?
A. Thrombophlebitis
B. Chronic Compartment Syndrome
C. Deep Vein Thrombosis
D. Acute Arterial Occlusion
E. Intermittent Claudication (common symptom of peripheral arterial disease)
Q. 2 – What further physical examination procedure should you perform?
A. Abdominal Examination (to check for possible aortic aneurysm)
B. Allen’s Test
C. Vibration Testing
D. Extensor Plantar Reflex
E. Valsalva Manoeuvre
Q.3 – Which supplementary investigation would best help establish the diagnosis?
A. Lumbo-pelvic X-ray series
B. Serum Lipid Profile
C. Full Blood Count
D. Doppler Ultrasound (Doppler ultrasonography is the main method used to diagnose PAD)
E. Glucose Tolerance Test
Q.4 – The rationale for the administration of aspirin therapy, for this patient, is based on which of aspirin’s pharmaceutical effects?
A. Anti-pyretic effect
B. Analgesic effect
C. Anti-platelet effect
D. Anti-neoplastic effect
E. Anti-alzheimer’s effect
Q.5 – The ankle-brachial index associated with rest pain is considered to be?
A. <0.9
B. <0.8
C. <0.7
D. <0.6 (ABPI = 1 (Normal) 0.9-0.6 (Claudication) 0.6-0.3 (Rest Pain) <0.3 (Impending Gangrene)
E. <0.5
References:
- Superstoked Magazine