Patient centered questions MCQs for assessment of "Clinical problem solving and Medical decision (62M)

A 62-year-old male with a history of long-standing diabetes mellitus and hypertension presented to the outpatient department with complaints of exertional shortness of breath and pedal edema since three years. He also complains of intermittent claudication of both lower limbs after walking for around 250 meters since last three years with improvement upon standing for a few minutes. He also complains of episodes of dizziness after walking and has been noted to have a regular daytime somnolence with nocturnal apneic episodes and snoring. He also complained of sudden diminished vision of one eye three months back.  

The general examination reveals a large central obesity and bilateral pedal edema along with hyperpigmentation of the skin and "peau de orange." His BMI is 34 kg/m2. 

On investigations, his pulmonary function test and 2D Echo and an adenosine driven thallium perfusion scan turn out to be normal. His Hb is 8g % with microcytic hypochromic anemia with reduced serum iron, reduced transferrin saturation and TIBC with normal serum ferritin. His serum creatinine is 1.9 mg % and his urine 24 hour protein excretion is around 2 g%. A polysomnography was done earlier. 

Which of the following parameter in the polysomnogram will likely be helpful in the management of his nighttime choking? 

1. Pulmonary arterial O2 saturation
2. Respiratory rate
3. Apnea-hypopnea index
4. Lower limb arterial doppler study
5. Coronary angiogram

A 62-year-old male with a history of long standing diabetes mellitus and hypertension presented to the outpatient department with complaints of exertional shortness of breath and pedal edema since three years. He also complains of intermittent claudication of both lower limbs after walking for around 250 meters since last three years with improvement upon standing for a few minutes. He also complains of episodes of dizziness after walking and has been noted to have a regular daytime somnolence with nocturnal apneic episodes and snoring. 

The general examination reveals a large central obesity and bilateral pedal edema along with hyperpigmentation of the skin and "peau de orange." His fundoscopy revealed a recovering vitreous hemorrhage with proliferative diabetic retinopathy. 

On investigations, his pulmonary function test and 2D Echo and an adenosine driven thallium perfusion scan turn out to be normal. His Hb is 8g % with microcytic hypochromic anemia with reduced serum iron, reduced transferrin saturation and TIBC with normal serum ferritin. His serum creatinine is 1.9 mg % and his urine 24 hour protein excretion is around 2 g%. His blood sugar profile is controlled on insulin glargine at night and bolus insulin thrice before meals. His Hba1c is 6.5. A sleep study showed multiple episodes of sleep apnoea during REM sleep and Doppler examination of lower limbs revealed normal arterial flow. His polysomniogram reports reveal apnea-hyponea index of 47. 

Which of the following is the best next step in the management of this patient? 

1. Continuous positive airway pressure
2. Reassurance 
3. Only weight loss
4. Surgical correction 
5. Only positional therapy   

A 62-year-old male with a history of long standing diabetes mellitus and hypertension presented to the outpatient department with complaints of exertional shortness of breath and pedal edema since three years. He also complains of intermittent claudication of both lower limbs after walking for around 250 meters since last three years with improvement upon standing for a few minutes. He also complains of episodes of dizziness after walking and has been noted to have a regular daytime somnolence with nocturnal apneic episodes and snoring. 

The general examination reveals a large central obesity and bilateral pedal edema along with hyperpigmentation of the skin and "peau de orange." His fundoscopy revealed a recovering vitreous hemorrhage with proliferative diabetic retinopathy. 

On investigations, his pulmonary function test and 2D Echo and an adenosine driven thallium perfusion scan turn out to be normal. His Hb is 8g % with microcytic hypochromic anemia with reduced serum iron, reduced transferrin saturation and TIBC with normal serum ferritin. His serum creatinine is 1.9 mg % and his urine 24 hour protein excretion is around 2 g%. His blood sugar profile is controlled on insulin glargine at night and bolus insulin thrice before meals. His Hba1c is 6.5. A sleep study showed multiple episodes of sleep apnoea during REM sleep and Doppler examination of lower limbs revealed normal arterial flow. 

Which of the following is the best next step in the management of this patient? 

1. Exercise
2. Restricting fluid intake
3. Cilostazol
4. Amlodipine
5. Stenting