View source for WBR0836

 {{WBRQuestion
|QuestionAuthor=Neeraja Danda M.B.B.S
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 50-year-old male presents to the office for pain in the right leg on walking for the last 6 months. The pain is present when walking both uphill and downhill but he gives no history of pain while resting and denies pain in the left leg. He has history of diabetes mellitus and hypertension and is on medication. 6 months ago he injured his right leg while moving some heavy boxes, he went to doctor and an X-ray of the right leg was normal. He has consumed 2 glasses of wine every day for the last 20 years and has smoked a pack of cigarettes every day for the last 15 years. What is the best initial test towards diagnosing the patient’s condition?
|Explanation=A 50–year-old male with a history of diabetes, hypertension and smoking who suffers from leg pain on walking (Claudication) suggests peripheral arterial disease (PAD).Peripheral arterial disease occurs due to blockage of blood supply to any peripheral body parts but mostly involves lower limbs. Smoking is one of the major risk factors for peripheral arterial disease. Physical examination of the involved limb may show loss of hair, loss of sweat. The best initial test for diagnosing peripheral arterial disease is ankle brachial index, the ratio of blood pressure measured in the ankles and brachial arteries. Ankle brachial index value <0.9 indicates peripheral arterial disease.  Treatment of PAD should include aspirin, cilostazol and smoking cessation.

'''Educational Objective:''' Ankle brachial index is the best initial test in diagnosing peripheral arterial disease 

'''References:''' Page 102 Master the boards Step 2 CK 2nd edition, Page 71 Master the boards step 3, 2009 edition.
|AnswerA=Repeat X-ray right leg

|AnswerAExp='''Incorrect''' His injury lifting heavy boxes might suggest a musculoskeletal cause, but the presentation of the patient suggests peripheral arterial disease more than any bone related pain.
|AnswerB=EKG
|AnswerBExp='''Incorrect''' EKG is useful for diagnosing myocardial infarction or arrhythmias.  Suspicion for either of these conditions should be low in this patient.
|AnswerC=Ankle Brachial index
|AnswerCExp=The best initial test for diagnosing peripheral arterial disease is ankle brachial index, the ratio of blood pressure measured in the ankles and brachial arteries. Ankle brachial index value <0.9 indicates peripheral arterial disease.
|AnswerD=Angiogram right leg
|AnswerDExp='''Incorrect''' Angiogram is the most accurate test for diagnosing peripheral arterial disease. However, due to angiogram’s invasive nature, the best initial test is ankle brachial index.
|AnswerE=HbA1C
|AnswerEExp='''Incorrect''' HbA1C can be assessed to monitor blood sugar control over a period of 6 weeks. Though diabetes mellitus is a cause of peripheral arterial disease, HbA1C has no role in diagnosing peripheral arterial disease

|RightAnswer=C
|WBRKeyword=Claudication , Peripheral Arterial Disease, Ankle Brachial Index
|Approved=Yes
}}