Question of the Week # 242

242) A 64 year old man is evaluated in the clinic for moderately severe pain in his both legs for the past 6 months. He describes the pain that occurs upon standing and worse on walking. The pain is worse walking downhill and slightly less while walking uphill. He reports that the pain interferes with his activities and he has to sit for about 30 minutes each time to obtain relief from the pain.  His history is significant for diabetes mellitus and chronic smoking about 1 pack per day for the past 45 years. On examination, he is afebrile and heart sounds are regular. Dorsalis pedis artery pulses are diminished bilaterally. Neurological examination is normal. Which of the following is the most appropriate next step in evaluating his pain?

A)     Clopidogrel

B)      Angiography

C)      MRI lumbar spine

D)     Ankle Brachial Index

E)     Supervised Exercise

9 Responses

  1. c

  2. dddddddddd

  3. lumar canal stenosis -pain more on downhill, so MRI spine

  4. C………Evaluating his pain? MRI.

  5. ccc

  6. c, first to do for dx.

  7. this question is genius .
    This patient has 2 coexisting disease
    1) Lumbar spinal stenosis : pain increase with downhill
    2) PAD : diminished pulse

    so we have to decide which disease is more life threatening and is our concern . Definitely PAD .

    I would go for D : ankle brachial index to screen the severity and the need to start tx .

    You won’t die of Spinal stenosis . At least acutely . But PAD can bring unwanted complication . E.g : P.E

    Presence of PAD indicates workup for arteriosclerotic process elsewhere e.g Coronary artery , carotid artery . we have to tx patient asap .

    Just my 2cents . would like to hear more opinion . Thanks 🙂

  8. C) Patient is complaining about pain due to spinal stenosis. we will do MRI first to get the diagnosis for his complaint.
    His complaint is not related to PVD although his peripheral pulses are diminished. We can do ABI also.
    I would do MRI first .

  9. D) Pt has both spinal stenosis and vascular claudication. However his neurologic exam is normal plus MRI is an expensive test. Moreover treatment of spinal stenosis is mainly supportive (NSAIDs, steroids, physiotherapy etc) so I wont go chasing after the stenosis. I will do ABI first, easy to do, cheap, has treatment if PAD (cilostazol) is present etc.

    MY guess is MRI would have been the answer if neuro exam was abnormal but it is normal here

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