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Lecture 16

RIU 436 Lecture Notes - Lecture 16: Thoracic Outlet Syndrome, Connective Tissue Disease, Raynaud Syndrome


Department
Radiation and Imaging - Ultrasound
Course Code
RIU 436
Professor
Miram Teft
Lecture
16

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1. A 59-year-old woman presented to our ultrasound lab after developing a
sudden onset of pain, cyanosis, and pallor of her left upper extremity while
getting ready for work. She has had a long history of a weak pulse in her left
arm and hand and a recent history of soreness in her left shoulder that she
attributed to early arthritis. Previous medical history is significant for deep vein
thrombosis in her left lower extremity following a long plane trip from Europe in
1996. She was treated with a 6-month regimen of Coumadin and has had no
subsequent thrombotic problems. She also has a history of
hypercholesterolemia, poorly controlled with diet. She is postmenopausal and
has been maintained on long-term hormone replacement therapy with both
Provera and estrogen. There is no history of cardiac pathology (left ventricular
thrombus, valvular disease, or arrhythmia) documented by echocardiogram and
electrocardiogram. On physical examination, there were no palpable brachial,
radial, or ulnar pulses. The blood pressure obtained on the right arm was 111/75,
and no pressure was obtained on the left arm due to no palpable pulses. The
left arm was cool to the touch and appeared more pale than the right arm.



A. Upper Extremity Arterial Occlusion
B. Thoracic Outlet Syndrome
C. Subclavian Steal
D. Primary Raynaud’s Disease
2. A 55-year-old Saudi female presents with classic bilateral discoloration of the
fingers ranging between pallor, bluish, and reddish, with mild pain and
numbness. The patient did not suffer from joint pain, swelling, or deformity and
did not exhibit skin rash, oral ulcers, or dysphagia. Her symptoms were
exacerbated by cold weather and stress. The patient is a lifelong nonsmoker.
She was initially treated with aspirin, nifedipine, and prednisolone by another
health facility, but no notable improvement was observed. Upon our initial
assessment, she exhibited no features of connective tissue disease and the
physical examination was remarkable for bilateral cyanosis of the fingertips,
with a left middle finger ulcer, whereas a lower limb examination revealed
bluish discoloration of the right and left second and third toe tips. Distal pulse
and motor and sensory evaluations were normal. Laboratory investigation for
autoimmune analysis and serology and malignancy screening were normal .
The patient was admitted to our hospital in July 2010 with severe digital pain
and ulceration. Magnetic resonance angiogram of her upper extremities did not

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show any features of vasculitis, aneurysm, or stenosis. Computed tomography
(CT) scanning of the aortic arch demonstrated a normal aorta and normal
branches with no obvious vascular abnormality.

3. A. Thoracic Outlet Syndrome
4. B. Hypothenar Hand Syndrome
5. C. Primary Raynaud’s Disease
6. D. Secondary Raynaud’s Disease
3. A 54-year old Caucasian woman was admitted to hospital because of severe
acute pulmonary edema. She had a 20-year history of hypertension, but recently all
medications were discontinued because of an episode of syncope and a finding of
very low arterial pressure (95/60 mmHg in the right arm). She complained of
previously formless symptoms, such as malaise, weakness, fatigue and fever.
Symptoms had presented occasionally since she was 35-years old. A relapse of these
symptoms occurred 2 weeks before admission.
At physical examination there was a remarkable blood pressure discrepancy
between the right and left arms. Blood pressure was undetectable in the left
arm,but was 95/60 mm Hg supine in the right arm. Both the left radial and left
brachial pulses were impalpable.

Positive laboratory findings included elevated erythrocyte sedimentation rate (45
mm/1st h) and C-reactive protein levels (5.3 mg/dL). Blood cultures, venereal
disease research laboratory test, and autoimmune serological findings were
negative.


A. Buerger’s Disease
B. Takayasu’s Arteritis
C. Primary Raynaud’s Disease
D. Subclavian Artery Thrombosis


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4. A 63-year-old male was admitted to our department complaining of pain and    
swelling behind his left knee aggravating throughout the last month. The patient had a
history of chronic renal failure under hemodialysis, hypertension, and diabetes mellitus
and was a heavy smoker. He had undergone saphenous vein ablation on the right leg
due to significant venous insufficiency. There was no history of any trauma or
local/systemic infection.
On examination, a palpable pulsatile mass in the upper popliteal fossa was
revealed. Left distal pulses were weak, while the ankle brachial index (ABI) for the
left and right limb was 0.8 and >1, respectively.

A. Pseudoaneurysm
B. AV Fistula
C. Aneurysm
D. Popliteal Artery Thrombosis
5. A 20 year old male presented to the medical officer at the Australian Defence  
Force’s point of entry in the Middle East theatre of operations 6 days after sustaining a
straddle injury to the perineum while on leave. He was due to return to his unit later
that week and was concerned that since the accident his penis had remained semi
erect. At the time of the injury he had pain and bruising around the perineum. The
initial pain settled to a dull ache. He remained able to ejaculate and reported no
haematospermia or pain with ejaculation or urination. He also reported he was unable
to achieve a full erection. On examination he was walking normally, there was
resolving bruising around the perineum and scrotum but no lacerations or skin tears
and his prostate and rectal examination were normal. The Tests were normal for the
examination. Urinalysis was normal. He had no other health issues and no significant
history of any medical or surgical problems. An ultrasound was reported as normal
(Doppler not available) as was a CT scan.

A. Arterial Insufficiency
B. Venous Leakage
C. High Flow Priaprism- blood cannot get in
D. Low Flow Priaprism
6. A 51-year-old African-American male presented to the emergency room with a
painful erection that had been present for over 4 hours. The patient's past medical
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