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Medical Differential Diagnosis Practice Case #3 (Leg Pain)

Updated on April 8, 2013
Medical Differential Diagnosis Practice Case #3 (Leg Pain) Picture: Wikimedia Commons
Medical Differential Diagnosis Practice Case #3 (Leg Pain) Picture: Wikimedia Commons
Picture: Wikimedia Commons
Picture: Wikimedia Commons

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. –

PS - If you found these practice cases useful, be sure to browse through my other similar training questions as well, and be sure to share it with your fellow students / colleagues / friends. If you have any questions, please ask them in the comments section below. Thank you.


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

- Vondt.net

Comments

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    • profile image

      Lisa 

      4 years ago

    • Dr. Haddox profile image

      Dr Freddie Haddox 

      6 years ago from a Franklin, Tennessee native, who travels globally.

      This common clinical situation is one that will be seen time and time again at the primary health care level where I worked as a physician for 20 years. Medical students need to know this one "cold." They will surely see it, again and again and again. Dr. haddox

    • Resolver2009 profile imageAUTHOR

      Resolver2009 

      6 years ago from Bournemouth, UK / Oslo, Norway

      ..."I'll be sure to run more expensive tests the next time a 70 year old with a detached limb comes to see me! ".. Surely Kimh039, you mean more extenstive tests? ;)

    • kimh039 profile image

      Kim Harris 

      6 years ago

      This was fun, resolver. I judged completely by the picture and assumed a phantom leg syndrome 2nd to left leg amputation. I'll be sure to run more expensive tests the next time a 70 year old with a detached limb comes to see me! Seriously, this was very interesting and educational even though I only got 2 of 5 correct answers. Thanks.

    • Dr. Haddox profile image

      Dr Freddie Haddox 

      7 years ago from a Franklin, Tennessee native, who travels globally.

      This was a well written and fun case. Back in the 60s and 70s when I was a young person learning and practing medicine we used to see these signs and symptoms a lot. It was a lot of fun watching this case unfold and knowing that some things never change. Thank you. And take care.

      Dr. Haddox

    • Resolver2009 profile imageAUTHOR

      Resolver2009 

      7 years ago from Bournemouth, UK / Oslo, Norway

      Well done Enlydia! :)

      The last one, do you mean the ankle-brachial pressure index? It is merely a comparison of the blood pressure of the lower limbs versus the upper limbs; they should be 1, meaning that they are the same (although lower limbs tend to have a slightly higher BP). If it is below 1, there is something impeding on the ankle pulse pressure diminishing it, i.e. something blocking the peripheral arteries.

      Be sure to check out the other practice cases I have published as well if you liked this one. :)

    • Enlydia Listener profile image

      Enlydia Listener 

      7 years ago from trailer in the country

      I got three out of five right. The last one, I have no experience with.

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