Blood Vessel and Lymphatic Disorders

Question 1

A 60 y/o male smoker presents with a 6 month history of impotence along with calf, thigh, and buttocks claudication. The femoralsare not palpable. Angiogram is shown. This man has a (an):

need pic, aorto iliac artery is occluded

Answer 1

aorto-iliac occlusion.

Question 2

Treatment for artery occlusion

Answer 2

1. Smoking cessation and BP control
2. ASA and/or clopidogrel(Prevents MI, CVA , etc).
3. Cilostazol(Pletal/phosphodiesterase type 3 inhibitor –inhibits platelet aggregation and dilates vessels) 100 mg BID
4. Pentoxifylline(Trental/phosphodiesterase inhibitor with antihemorrheologicactivities) 400 mg TID
5. Ramipril*
6. Statin (rosuvastatin40 mg daily)
7. Stent
8. Axillo-femoral bypass; Aorto-fem bypass
9. Intermittent calf compression. Angiogenesis with injection of mononuclear cells.`

Question 3

antiplatelet drugs

Answer 3

aspirin thromboxane a2

Cilostazol Pentoxifylline kep 5amp from going to camp

Question 4

P2Y12 signalling modulates thrombin generation

Answer 4

ADP feedback loop

Question 5

A 60 y/o diabetic male presents with cramping pain in both calves with walking2-4 blocks. The femoral arterial pulses seem somewhat diminished in the groin, the left popliteal and left pedal pulses are diminished. The right pedal pulses are absent. The Ankle/Brachial index is 0.5 on the left and 0.1 on the right. There is no hair on the right toes and the patient has dependent rubor on the right. The patient most likely has severe occlusion of the

Answer 5

superficial femoral

Question 6

higher the blockage the sooner you will

Answer 6

have pain

Question 7

Ankle/Brachial index normal is

Answer 7

.9-1

Question 8

If the profunduswere involved, the claudication would

Answer 8

occur much earlier

Question 9

what artery would be the source of collateral network in pt with superficial femoral blocked

Answer 9

profundis

Question 10

with profundus you could only walk

Answer 10

1-2 blocks

Question 11

with superficial femoral you can walk

Answer 11

2-4 blocks

Question 12

under what conditions would it have been possible to have a more normal ABI on the right (ie.8 or .9) and still have poor circulation?

Answer 12

When the vessels are calcified*as in diabetics. This does not allow
practical use of ABI and thus one must resort to wave form analysis.

failed reading with cuff

Question 13

Osler’s sign or maneuver?

Answer 13

Pseudohypertension because
of calcified vessels.

falsely high

Question 14

Treatment of superficial and common femoral and popliteal stenosis

Answer 14

• 1. structured walking program
• 2. Fem-pop bypass*

*absolute indication for surgery –rest pain and non-healing ulceration

Question 15

A 55 year old man is seen for progressive bilateral leg and calf pain
with ambulation and relief with sitting down in a chair. History is positive for hypertension and the patient is on an ACE inhibitor. Physical examination reveals an S4. Present BP is 130/60. He has a “simian gait” and complains of worse pain with extension of his back and improvement with bending forward. Calves are tender.
Pedal pulses are questionably diminished. Which test will most likely be positive?

Answer 15

lumbar mri

Progressive narrowing of the spinal canal may occur alone or in combination with acute
disc herniations. Lumbar spinal stenosis (LSS) remains the leading preoperative diagnosis
for adults older than 65 years who undergo spine surgery.

Question 16

s4

Answer 16

atrial kick from unrelaxed ventricle (ventricle is stiff so it makes noise going in)

bc hypertensive heart disease

Question 17

why are pedal pulses diminished

Answer 17

bc dorsalis pedis may not be where it belongs

Question 18

spinal stenosis may look like peripheral vascular disease but it gets better when

Answer 18

nerve pain from compression

Question 19

Lumbar spinal stenosis

Answer 19

Absence of pain or improvement of symptoms when seated assists in ruling in LSS. Patients with significant lumbar spinal canal narrowing report pain, weakness, and numbness in the legs while walking. Compressed nerve roots become ischemic due to stenosis. This is the hallmark of neurogenic claudication. The pain is relieved when the patient flexes the spine by, for example, leaning on shopping carts or sitting. Flexion increases canal size. The most common nerve affected is the L5, with associated weakness of extensor hallucislongus. Neurogenic claudication pain is exacerbated by standing erect and downhill ambulation and is alleviated with sitting, squatting, and lumbar flexion.

Question 20

Lumbar spinal stenosis Neurogenic claudication pain is exacerbated by

Answer 20

standing erect and downhill ambulation

Question 21

Lumbar spinal stenosis Neurogenic claudication pain is alleviated with

Answer 21

sitting, squatting, and lumbar flexion.

Question 22

Tibial and pedal artery occlusion A 45 y/o diabetic presents with burning, dorsal foot pain that is relieved by getting up or dangling the foot. How do you know this is not diabetic neuropathy? How is the diagnosis made? What is the treatment?

Answer 22

relieved by dangling
MRA.
Vein bypass to distal tibial or pedal arteries. (sometimes vessels cant take the pressure and they rupture when distal)

Question 23

A 35 y/o male from south Africa presents with sudden onset painin the right lower extremity. The leg is pale, weak, and numb. The pedal pulses are absent and the foot is cold. The heart rhythm is irregular. What has happened?

Answer 23

Acute arterial occlusion of a limb

neuropathy bc no blood is getting down there

arteries feeding nerve are blocked and so you get numb

afib, he has thrown a clot

Question 24

Acute arterial occlusion of a limb

Answer 24

A. 50% of cardiac emboli go to the legs.

B. With loss of light touch, surgery should be done immediately.

C. Before revascularization, NaHCO3should be administered. (lactic acidosis from hypoxia)

D. Cause is sometimes due to thrombosis.

E. Pedal pulse are not palpable.

Question 25

6 Ps of acute arterial occlusion

Answer 25

Pain Pallor Paralysis Paresthesias (most concerned about this one) Pulselessness Poikilothermia* (irregular temp, ice cold)

Question 26

A 58 y/o hypertensive, diabetic, female presents with dizziness, diploplia, dysphagia, dysarthria, dysmetria, and ataxia of 50 minutes duration. The patient is having which type of an event?

Answer 26

Vertebro-basilar TIA

Question 27

dizziness, diploplia, dysphagia, dysarthria, dysmetria, and ataxia

Answer 27

The Dsof VB TIAs brainstem function having to do with these things

Question 28

The Lateral Medullary Syndrome

Answer 28

with occlusion of vertebral or PICA = the Ds plus numbness in contralateral arm or leg and ipsilateral face, with Horner’s syndrome. whalenberg or lateral medullary syndrom

Question 29

Carotid Territory TIA

Answer 29

Aphasias, unilateral weakness or numbness, and amaurosis fugax (sudden loss of vision in one eye, everything is unilateral)

Question 30

The Lateral Medullary Syndrome with occlusion | of vertebral or PICA

Answer 30

not asking this... ringing in the right ear, dizziness and right facial pain. There is nystagmus on right lateral gaze. There is right perceptive deafness. Intention tremor is present on the right with falling to the right with Romberg position. There is loss of pain and temperature over the right face and opposite trunk and extremities with ptosis of the right eye and constriction of the right pupil..

Question 31

aphasias

Answer 31

left you would get expressive or receptive

Question 32

A 45 y/o hyperlipidemic, diabetic female has had abdominal pain lasting for 2 hours after meals for the past 3 years. She has had a 20 lb weight loss over the past 6 months related to fear of eating. She presents suddenly with periumbilical pain, but no significant clinical abdominal findings except for bloating. The patient has a (an)

Answer 32

mesenteric occlusion marker for this is palpation and no pain and they are complaining about it

Question 33

abdomial angina

Answer 33

pain after meals from no blood while trying to digest

Question 34

mesenteric occlusion treatment

Answer 34

•Angioplasty and stent versus aorto-celiac or superior mesenteric bypass rt iliac to sma sephanous graft lt iliac to ima sephanous graft

Question 35

A 65 y/o female with a history of polycythemia and frequent phlebotomies presents with abdominal pain and swelling. Two months ago she had an episode of amaurosis fugax and two weeks ago, she had left sided numbness that lasted for 10 minutes. She has been having abdominal pain after meals for the past 6 months. Hbis 18 gm with WBC of 13,000 and platelets of 350,000. Exam shows abdominal enlargement with dullness to percussion in the flanks. A CT angiogram is performed and shows portal vein thrombosis. What is most unusual in this patient?

Answer 35

blood clots on both sides and clotting in venous and arterial system Portal vein thrombosis

Question 36

Basis of a red clot

Answer 36

venous side fibrinogen forms and red cells get caught Caused by multiple thrombophilic* and /or hypofibrinolytic** factors, mostly inherited. Also due to acquired risk factors (pregnancy, BCPs, high dose steroids, immobilization, surgery, and foreign bodies in the blood stream/catheters

Question 37

Basis of a white clot

Answer 37

aterial side due to platelet aggregation Caused by smoking, hypertension, hyperlipidemia, DM, cholesterol emboli.

Question 38

What causes arterial and venous clotting? said wont be on test

Answer 38

Heparin induced thrombocytopenia (HIT) Paroxysmal Nocturnal Hemoglobinuria(PNH) Myeloproliferative disease (especially JAK 2) Anti Phospholipid Antibody Syndrome (APLAS) Anti Cardiolipin Antibody Syndrome (ACLA) Hyperhomocysteinemia Thromboangitis obliterans (Buerger’sdisease: vasculitis of arteries and veins). Nephrotic syndrome (antithrombinIII, protein S and C deficiency). Right to left shunt Popliteal artery aneurysm

Question 39

Aortic Aneurysms

Answer 39

* USPFTS: One time screening (for AAA) of 65-75 y/o males who have ever smoked. Insufficient evidence for women. * Truly significant at 5-6 cm. (when you ahve to operate) * Thrombosis in aortic aneurysms -no anticoagulation * Do coronary surgery prior to aneurysm repair.

Question 40

What is the treatment for an aortic aneurysm?

Answer 40

* Labetolol20 mg over 2 min IV (want to drop bp), then 40 -80 mg q 10 min * Esmolol0.5 mg/kg IV * Nitroprusside50 mg in 1000 D5 at 0.5 mL/min * Surgical repair or endovascular graft (older pts)

Question 41

A tall, thin 35 y/o male presents for a flight physical to renew his license for Delta. During the exam he is found to have a 3/6 diastolic decresendo murmur at the base, with a 2/6 systolic murmur at the apex that lengthens with standing and shortens with handgrip. History is positive for a prior pneumothorax. Which would be an additional finding in this patient? on the test

Answer 41

problem with collagen tissue so proglem at valve rings Aortic root dilation as it dialated it went down to the ring

Question 42

diastolic decresendo murmur at the base

Answer 42

aortic insufficiency

Question 43

systolic murmur at the apex that lengthens with standing and shortens with handgrip

Answer 43

mitral regurg

Question 44

Which is associated with a dissecting aortic aneurysm?

Answer 44

dissection into the intima sharp intense chest pain inferior wall mi diastolic murmur htn paraplegia gets close to right coronary artery and you get an infaction in the inferior wall 4-5 % of people have arteries going to spinal cord so you get paraplegia

Question 45

Can also see dissection in

Answer 45

pregnancy, bicuspid aortic valve, and coarctation.

Question 46

Know the symptoms of a dissecting ascending thoracic aortic aneurysm versus a descending thoracic aortic aneurysm as given in Lange’s CMDT!

Answer 46

open langs

Question 47

What is the medical treatment for an expanding or dissecting aortic aneurysm?

Answer 47

?

Question 48

What produces mediastinal widening? not on test

Answer 48

* Artifact –patient rotated * Mediastinal Mass –T and B cell lymphoma, teratoma, thyroid, thymus = 4 Ts * Vessels –aortic aneurysm * Anthrax

Question 49

Peripheral Artery Aneurysms

Answer 49

* An easily palpable popliteal pulse may well be an aneurysm which can present with loss of distal pulse with acute leg or foot pain * Popliteal aneurysms account for 70% of peripheral arterial aneurysms –risk include thrombosis and embolization. * In treatment, surgery is indicated for peripheral embolization, > 2cm or a mural thrombus. Often can be conservative if light touch remains in tact

Question 50

Which of the following predisposes to thrombophlebitis?

Answer 50

trauma

Question 51

Virchow’s Triad

Answer 51

Hypercoagulability (lack of fibrinolysis protein cs and antithrombin deficiencies) Stasis Trauma

Question 52

This patient had presented with a post-phlebiticsyndrome involving the left leg. The clot in the left iliac vein was related to pressure from the

Answer 52

right iliac right iliac artery is crossing over left iliac vein, sets up clots in people iliac clot occurs on the left side, called may ferners syndrome May –Thurnersyndrome: may account for 30% of all venous events in the US each year.

Question 53

A 59 y/o male with pancreatic cancer presents with a two week history of a swollen left leg with calf tenderness. Physical exam shows a superficial phlebitis of the left arm. The cause of these findings is most likely:

Answer 53

systemic hypercoagulability. Trousseau’s syndrome

Question 54

Trousseau’s syndrome

Answer 54

Armand Trousseau who diagnosed himself with gastric cancer. Involves mucin(glycans) producing epithelial cancers that activate platelet and leukocyte (P and L) selectins(CD62/glycoproteins or cell adhesion molecules/CAMs) that lead to platelet rich microthrombi(seen most often in adenocarcinoma of the lung). Thrombogenic cancers: gastric, esophageal, lung, pancreas, renal, ovarian, AML, non-Hodgkins lymphoma*. adenocarcinomas you activate and l selectins so they get more sticky and you get a clot

Question 55

Venous Ulcers need to know this

Answer 55

History of trauma, pregnancy, and varicose veins Medial malleolus Superficial, irregular margins Ruddy, beefy (bc artery is good), fibrinous, granulation Edema Dermatitis Lipodermatosclerosi –indurated Hyperpigmentation -hemosiderin Moderate to heavy exudate Cap refilling -

Question 56

Arterial ulcers need to know

Answer 56

History of smoking, rest pain claudication Site of pressure Deep, “punched out” with sharp borders Bed pale grey or yellow Dry necrotic base with eschar Lateral Pale,hair loss, cold feet, atrophic skin, no pulses Cap filling >4-5 sec. Elevation pallor

Question 57

Neuropathic ulcer*

Answer 57

History of numbness Common in DM Pressure site Variable depth Surrounding callus Cap refilling normal ABI = normal firm ridge and callous around it

Question 58

Chronic leg ulcers

Answer 58

PAD Venous insufficiency DM Autoimmune diseases (Felty’s) SS anemia Vasculitis Panniculitis Infection (fungal) Hypertension (Martorell’s)

Question 59

Septic Superficial Thrombophlebitis don't worry about

Answer 59

* Vancomycin15 mg/kg IV q 12 hrs | * Ceftriaxone 1 gm IV q 24 hrs

Question 60

Phlegmasia Cerulean Dolens* know this

Answer 60

Literally inflammatory (edematous), blue, and painful, ie. painful, sky blue and inflamed! Due to primary venous insufficiency with secondary arterial insufficiency (not so in AF where emboli cause primary arterial occlusion and pallor occurs). Most common cause is cancer, though may be obesity, old age, immobilization, or other procoagulantconditions (Factor V Leiden, etc) so much venous insufficiency the leg swells up and blocks the artery, can tell primary problem is venous bc it is edematous and purple not white goes with cancers

Question 61

Phlegmasia alba dolens

Answer 61

is white one so it is an artery problem

Question 62

Phlegmasia Cerulean Dolens* | Treatment

Answer 62

1. Fluid 2. Anticoagulation 3. Evaluate for cancer

Question 63

A 64 y/o male with lung cancer presents with dizziness, blurred vision and headache. Physical exam shows flushed faciesand dilated neck veins. This patient has developed

Answer 63

vena cava obstruction

Question 64

Non small cell lung cancer is the most common cause of

Answer 64

vena cava syndrome* followed by small cell and then lymphoma . Pancoastssyndrome is more often d

Question 65

Causes of SVC obstruction

Answer 65

Cancer Chronic fibrotic mediastinitis(reaction to Histoplasmosisantigen) DVT from arm veins Aortic arch aneurysm Constrictive pericarditis mroe swelling in face in morning bc gravity helps to drain

Question 66

What causes lymphedema and what are its characteristics

Answer 66

partial agenesis of lymphatics pitting edema without ulcers, varicose veins or stasis pigmentation milroys disease stewart treves syndrome

Question 67

milroys disease 1892

Answer 67

–(described in a missionary from India) –congenital lymphedema with break in the VEGFR 3 gene (know this (the gene controls lymphogenesis)

Question 68

stewart treves syndrome wont ask this looks like lymphadema

Answer 68

actually a hemangiosarcoma rather than a lymphangiosarcoma due to local immunodeficiency (possibly radiation contributes)

Question 69

adiposadolorosa

Answer 69

doesnt involve feet is how you differentiate from lymphedema adiposa deloroso, pain in fatty tissue lipidema