3 ms·

That test case involved a 76-year-old patient with severe pain in his low back, buttocks and calves when he walked. The pain started a few days after he had bee

That test case involved a 76-year-old patient with severe pain in his low back, buttocks and calves when he walked. The pain started a few days after he had been treated with balloon angioplasty to widen a coronary artery. He had been treated with the blood thinner heparin for 48 hours after the procedure. The man complained that he felt feverish and tired. His cardiologist had done lab studies that indicated a new onset of anemia and a buildup of nitrogen and other kidney waste products in his blood. The man had had bypass surgery for heart disease a decade earlier. The case vignette continued to include details of the man’s physical exam, and then provided his lab test results. The correct diagnosis was cholesterol embolism — a condition in which shards of cholesterol break off from plaque in arteries and block blood vessels. ———————— Strange answer.

viraptor 2y ago
Why strange?
- Pigalowda 2y ago
  In my opinion the answer doesn’t seem to be parsimonious or allow much gamemanship by the question stem. The patient has post procedure back pain and lower extremity pain (likely femoral access for his angioplasty) and acute kidney injury. Normally I would go for a few things such as an iatrogenic complication like aortic dissection from the angiocath. His anemia, back pain, AKI, and malaise are also be worrisome for retroperitoneal hemorrhage, especially with recent anticoagulation with heparin and catheterization. I might also think of heparin induced thrombocytopenia and get a HIT panel given recent heparinization and anemia. Although I’m pretty sure it’s not this, info was given in the stem for it. The patient already had a CABG so he’s got multivessel coronary artery disease, now he’s also had a POBA. Does he also have ischemic cardiomyopathy? It wouldn’t be a surprise - acute decompensation could cause his AKI due to renal perfusion deficit. And lastly to get back and extremity pain with renal failure after an angio sounds like the catheter would have needed to disrupt a plaque in the descending aorta somewhere and then shower the kidneys and lower extremities with emboli. Anyways I’m a radiologist not a clinician so I’m sure there’s plenty of things I’m not thinking of. Plain old multifocal cholesterol embolism must be more common than I thought. So maybe strange for me but not for GPT or others.

viraptor 2y ago

Why strange?

Pigalowda 2y ago
In my opinion the answer doesn’t seem to be parsimonious or allow much gamemanship by the question stem. The patient has post procedure back pain and lower extremity pain (likely femoral access for his angioplasty) and acute kidney injury. Normally I would go for a few things such as an iatrogenic complication like aortic dissection from the angiocath. His anemia, back pain, AKI, and malaise are also be worrisome for retroperitoneal hemorrhage, especially with recent anticoagulation with heparin and catheterization. I might also think of heparin induced thrombocytopenia and get a HIT panel given recent heparinization and anemia. Although I’m pretty sure it’s not this, info was given in the stem for it. The patient already had a CABG so he’s got multivessel coronary artery disease, now he’s also had a POBA. Does he also have ischemic cardiomyopathy? It wouldn’t be a surprise - acute decompensation could cause his AKI due to renal perfusion deficit. And lastly to get back and extremity pain with renal failure after an angio sounds like the catheter would have needed to disrupt a plaque in the descending aorta somewhere and then shower the kidneys and lower extremities with emboli. Anyways I’m a radiologist not a clinician so I’m sure there’s plenty of things I’m not thinking of. Plain old multifocal cholesterol embolism must be more common than I thought. So maybe strange for me but not for GPT or others.