Vascular

Question 1

DVT risk factors
using the mnemonic “THROMBOSIS”

(Guess as many as you can)

Answer 1

Travel
HRT
Recreational drugs
Old (60+)
Malignancy
Blood d/o (factor V leiden, Antithrombin III def, etc) 
Obesity/Obstetrics/OCPs
Surgery/Smoking
Immobilization
Sickness (CHF/MI, nephrotic syndrome, vasculitis)

Question 2

List Virchow triad for DVT

Answer 2

Hypercoagulability
Endothelial damage
Venous stasis

Question 3

Localized unilateral swelling, feeling of tightness or heaviness of lower extremity
Warmth, erythema
Progressive tenderness, dull pain
Fever
Homans sign: calf pain on dorsal flexion of the foot

diagnosis:

Answer 3

DVT

Question 4

Acute onset of symptoms of: 
Dyspnea & tachypnea
pleuritic chest pain
Cough +/- hemoptysis
Tachycardia & hypotension
JVD
\+/- DVT (unilaterally painful leg swelling)

Diagnosis:

Answer 4

pulmonary embolism

Features of massive PE:

• Syncope +/- pleural effusion
• Obstructive shock with circulatory collapse (saddle thrombus)
• Kussmaul’s sign (paradoxical rise in jugular venous pressure on inspiration)

Question 5

Diagnostic approach for suspected lower-extremity DVT :

Answer 5

Check D-dimer first for low suspicion of DVT
Negative (< 500 ng/mL): DVT ruled out
Positive (≥ 500 ng/mL) → Duplex U/S

Question 6

Pain, tenderness, induration, and erythema overlying a superficial vein, often with a palpable cord

diagnosis and next best step in management?

Answer 6

1. Superficial thrombophlebitis
   * palpable cord (the thrombosed vein)
2. get Compression ultrasound

Question 7

Management of DVTs (2)

Answer 7

1. LMWH (Enoxaparin)
2. IVC Filter
   For patients with contraindications for anticoagulation;
   (active bleeding, recent major surgery, recent intracranial hemorrhage)

Question 8

Causes of Pulmonary Embolism are

FATAL

Answer 8

Fat, Air, Thrombus, Amniotic fluid, and Less common (malignancy, bacteria)

Question 9

Pathophysiologic response of the lung to PE arterial obstruction:
(Just read over)

Answer 9

Infarction and inflammation of lung →
pleuritic chest pain & hemoptysis

Impaired gas exchange →
ventilation-perfusion mismatch

Cardiac compromise →
Elevated pulmonary artery pressure → RV pressure ↑

Pulmonary vasoconstriction →
bronchospasm

Question 10

ABG in pulmonary embolism shows:

1. ↑/↓ SaO2
2. ↑/↓ Alveolar-arterial gradient
3. Respiratory (acidosis/alkalosis)

Answer 10

↓ SaO2
↑ Alveolar-arterial gradient
Respiratory alkalosis

Question 11

Imaging to confirm PE

Answer 11

CT angiography

CT PA/ CT spiral

Question 12

Treatment of Pulmonary Embolism

Answer 12

1. Stabilize patient and provide supportive care*.
2. Nonmassive PE: LMWH (AC) or IVC filter
   Massive PE: Thrombolytics (tPA/alteplase) → embolectomy (unable to use tPA or unsuccessful)

*Supportive care
Hypotension or obstructive shock → IVFs
Respiratory support/ O2 supp

Question 13

Cx of Pulmonary Embolism (2)

Answer 13

Right ventricular failure
Sudden cardiac death due to pulseless activity

Atelectasis
Pleural effusion
Pulmonary infarction

Question 14

Recent history of orthopedic surgery
Hypoxia
Neurological symptoms
Petechial rash
thrombocytopenia

Diagnosis

Answer 14

Fat embolism

Question 15

Recent history of
surgery
Barotrauma (mechanical ventilation)
or
Central venous catheter (insertion and removal)
sudden hypoxia

Diagnosis

Answer 15

Air embolism

Question 16

Intrapartum/post partum woman
with acute onset of 
hypoxia; dyspnea
hypotension; cardiac arrest
DIC

Diagnosis

Answer 16

Amniotic Fluid Embolism

Tx: Emergency cesarean delivery & supportive

Question 17

Clinical features:
Generalized or localized lower extremity pain, cramping, pruritus and/or swelling
Edema starting at ankle
Yellow-brown or red-brown skin pigmentation of the MEDIAL ankle or ulcers
varicose veins

Answer 17

Chronic Venous insufficiency

Lipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg

Atrophie blanche: White, coin- to palm-sized atrophic plaques

Question 18

If conservative management of chronic venous insufficiency fails or if diagnosis is uncertain what do next?

Answer 18

Duplex ultrasonography

Question 19

Chronic venous insufficiency requires definitive treatment if there is recurrent:

Bleeding Ulcers
or
Superficial Thrombophlebitis

Technique: ___ therapies

Answer 19

vein ablation

Question 20

Peripheral Venous Disease Ulcers
Most frequently occur just above the __
Shallow ulcer with __ borders
mildly painful

Answer 20

medial malleolus/ankle
irregular

(pt likely has a DVT)

Tx: elevation, compression stockings, Zinc-Copper wrap/paste

Question 21

__ should be performed in any nonischemic wound that fails to improve after 3 months of treatment.

Answer 21

Biopsies

Question 22

Peripheral Arterial Disease Ulcers:

• usually located over ___ or ___
• resting pain over ____
• claudication over calves
• low ABI (like ≤ __)

Risk factors:
-h/o atherosclerosis, smoking

Answer 22

dorsum of foot/ tips of toes

metatarsal heads

0.9

Stage I: asymptomatic
Stage II: pain on exertion
Stage III: at rest

Question 23

-

Claudication is NOT a surgical disease.
Don’t use compression socks.

Answer 23

Treat underlying cause (smoking cessation, statin, glycemic control)

Exercise program (exercise > clopidogrel)

last line options:
Cilostazol (phosphodiesterase III inhibitor vasodilator)
Peripheral artery bypass surgery (revascularization)

Question 24

Pseudoclaudication → presents like claudication, but at least one good peripheral pulse usually due to __

Answer 24

spinal stenosis (around L5-S1)

Question 25

Resting ABI > 1.4 Interpretation: | Medial ____ with non-compressible vascular wall

Answer 25

calcific sclerosis *Ankle-brachial index (ABI) = systolic ankle BP: systolic brachial BP

Question 26

``` CEAP classifications of venous insufficiency 0. No palpable/visible sxs on legs 1. 2. 3. edema 4. skin changes (sclerosis, eczema, pigmentation) 5. healed ulcers 6. ```

Answer 26

1. Telangiectasia/ reticular veins 2. Varicose veins 6. Active ulcers

Question 27

MCC of Subclavian steal syndrome

Answer 27

Atherosclerosis

Question 28

Imaging for Subclavian steal syndrome

Answer 28

ultrasound | shows reversal of blood flow

Question 29

Treatment for Subclavian steal syndrome in symptomatic patients

Answer 29

angioplasty/stenting or surgical revascularization

Question 30

``` Clinical features: Limb ischemia (on exertion) Pain, paresthesia Pale, cool skin Weak, delayed radial pulse Disparity in BP > 15 mm Hg Dizziness, vertigo, syncope Diagnosis: ```

Answer 30

Subclavian steal syndrome **Neurologic sxs (due to vertebrobasilar insufficiency)

Question 31

Subclavian steal syndrome 2/2 ___ of the subclavian artery proximal to the origin of the vertebral artery → reversal of blood flow in ipsilateral vertebral artery

Answer 31

stenosis

Question 32

Associated with polymyalgia rheumatica (PMR)

Answer 32

Giant cell temporal arteritis | elderly women

Question 33

Immediate administration of ____ is crucial to lowering the risk of permanent vision loss in patients with giant cell arteritis.

Answer 33

high-dose glucocorticoids

Question 34

Laboratory test ↑ in GCA

Answer 34

↑ ESR

Question 35

Gold standard diagnostic for any patient | with suspected Giant cell temporal arteritis

Answer 35

Temporal artery biopsy

Question 36

Complications of Giant cell temporal arteritis (3)

Answer 36

Permanent vision loss Stroke Aortic aneurysm and/or dissection

Question 37

Carotid artery dissection is a rare complication of seemingly minor oropharyngeal trauma (a fall with object in mouth), or neck strain/manipulation/penetration (yoga, sports). The dissection can cause thrombus formation, which occurs over hours to days and can extend into which 2 arteries?

Answer 37

MCA & ACA

Question 38

Pt presents with neck pain "thunderclap" headache & ischemic stroke like sxs: hemiparesis, facial droop, aphasia.  Diagnosis and next best step in management?

Answer 38

Carotid artery dissection CT neck or MRA

Question 39

Used to diagnose peripheral artery disease. 

Answer 39

ankle-brachial index

Question 40

Painful ulcer at at the tips of the toes (least perfused areas) or dorsum of foot. Cool, pale skin with dermal atrophy; and diminished pulses. 

Answer 40

arterial ulcer | s/t PAD

Question 41

____ used to diagnose venous insufficiency, stasis, or obstruction. 

Answer 41

Duplex ultrasonography

Question 42

Ulcer on the leg above the Medial Malleolus with edema, varicose veins, and stasis dermatitis (hairless, rough/smooth)

Answer 42

Venous ulcers | s/t Venous stasis