A 59 year old man attended his GP complaining of pain in his arms

A 59 year old man attended his GP complaining of pain in his arms.He noticed the pain particularly when lifting weights in his left hand and during exercising he would become weak and dizzy and nauseous and on two occasions had passed out without warning.He complained of neck pain and had recently had an MR scan of the neck and was told he had some 'wear and tear’changes in some of the vertebrae.
He had a past history of hypertension and hypercholestrolaemia and took regular atenolol and simvastatin.He was a smoker of 20 cigarettes per day and drank approximately 20 units of alcohol per week.He was a builder and was married with two adult childern.
On examination he was alert and orientated.His blood pressure was 150/78mmHg taken in the right arm and 120/67mmHg in left arm.His pulse was 80/minute and regular and there was evidence of bilateral carotid bruits.Heart sounds were normal and his chest was clear.On exam of neurological system, tone appeared normal,reflexes were depressed at the biceps and brachioradialis with a brisk triceps jerk.There was no demonstrable weakness, however there was some impared pinprick sensation over the thumb and middle finger in the left hand.There were no sign of atrophy or fasiculations.Cerebellar system appeared intact .Carotid doppler studies revealed.
70% stenosis of the left internal carotid artery.50% stenosis of the right internal carotid artery.The chest x ray was normal.
What is the most likely diagnosis in this patient?

  • A .cervical spondylosis
  • B.Left carotid artery disease
  • C.Pancoast tumour.
  • D.Subclavian steal syndrome
  • E.Thoracic outlet obstruction.

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