416) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. She presents with increasing swelling and mild pain in her right lower extremity over past several months. The pain is present all the time and does not get better with rest. The swelling has progressively increased and now, she has unsightly thickening of the skin. On examination, there is non-pitting edema of the entire right lower extremity. The skin is thickened and can not be pinched and lifted.

Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease

415) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity upon walking. The pain gets better with rest. On examination, there is mild swelling of her right extremity with a 2 cm very shallow, clean, weeping ulcer on the medial malleolus with granulation tissue in the base. There is hyperpigmentation surrounding the ulcer. There is no “pitting”  of the swelling and the skin can be easily lifted from the subcutaneous tissues. Dorsalis pedis and posterior tibial artery pulses are mildly diminished.

Which of the following is indicated for her ulcer at this time?

A) Leg elevation and absorbent dressing

B) Antibiotics

C) Compression stockings

D) Anti-coagulation

E) Angiography

414) A 62-year-old software engineer presents with complains of mild pain and swelling in his right lower extremity which has been progressively increasing over the past 6 months. The swelling is more towards the end of the day. Pain is worse on walking or standing and gets better with rest. On examination, vitals are stable. There is non-pitting edema of right lower extremity below the level of the knee. The limb looks normal above the level of the knee. There is some bluish discoloration of the skin over the distal portion of the leg. Small intradermal bluish vessels are noted in the skin of her right lower extremity. Dorsalis pedis and tibial pulses are intact. Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease

413)  A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Now, she presents with pain in her right lower extremity that started about one week ago and is progressively worse. Over the last two days, she developed bluish discoloration of the right great toe . On examination, her vitals are stable. There is gross swelling of the entire right lower extremity with bluish discoloration of right great toe and extreme tenderness . Dorsalis and posterior tibial artery pulses are slightly diminished. Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease

410)  A 30 year old man presents to the emergency room after having had a syncopal episode. His girl friend reports he suddenly collapsed to the floor and lost consciousness for few minutes. There was no evidence of tonic clonic movements. After regaining his consciousness, he was completely alert and awake. He reports he has had sweating and nausea prior to the episode. He has had about 2 to 3 such episodes per year for past several years. He was admitted for similar episodes in the past and telemetry monitoring was uneventful. He denied any chest pain, shortness of breath or palpitations prior to the episode. He has no other significant medical problems. On examination, his vitals are stable. He is completely awake and oriented. There are no focal neurological deficits. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Holter Monitoring

B) CT scan of the Head

C) Tilt-Table testing

D) Carotid Doppler

E) Electrophysiology Study

409)  A 64 year old post-menopausal woman with history of  hypertension and coronary artery disease presents to the Emergency Room with severe left sided chest pain that started 1 hour ago at rest. The pain radiates to her left shoulder and her jaw. Her history is significant for per-cutaneous coronary intervention to the left anterior coronary artery and placement of drug-eluting stent 9 months ago. Her medications include aspirin, Clopidogrel, Metoprolol and Lisinopril. One week ago, she had a dental extraction procedure and had discontinued Aspirin and Clopidogel prior to the procedure. She was scared of bleeding and has not resumed these medications yet.  A chest X-ray is normal. An electrocardiogram reveals  5mm ST segment elevations in the anterior leads and reciprocal depressions in the inferior leads. Which of the following is the most appropriate explanation of this patient’s presentation?

A) Pericarditis

B) Re-Stenosis within the stent

C) Stent Thrombosis

D) Rupture of a new plaque in anterior coronary artery

E) Stenosis  from progressive atherosclerosis of anterior coronary artery

408)  A 52 year old post-menopausal woman with history of  hypertension, coronary artery disease and early stage breast cancer is evaluated in your office prior to breast reconstruction surgery. She was diagnosed with left breast invasive ductal carcinoma one year ago and has undergone left modified radical mastectomy followed by chemotherapy. Her history is significant for cardiac catheterization 3 months ago with coronary stent placement. Medications include Aspirin, Clopidogrel, metoprolol, lisinopril and anastrozole.  She is physically active and walks about 3 blocks per day with out any chest pain or shortness of breath.  Physical examination is unremarkable except fore evidence of left mastectomy. A resting electrocardiogram, chest x-ray , complete blood count and electrolytes are normal. Which of the following is the most appropriate recommendation at this time?

A) Schedule exercise stress test  and if normal, clear for surgery

B) Discontinue Clopidogrel and clear for surgery

C) Obtain 2D echo and if normal, clear for surgery

D) Admit, discontinue clopidogrel, start heparin and then, proceed with surgery

E) Recommend delaying surgery at least another 8 months