Breast and vascular

Question 1

definition of AAA

Answer 1

Abnormal dilatation of the aorta > 3cm diameter or >50% greater than normal artery above it

Question 2

describe the vascular Trendelenburg test

Answer 2

Question 3

describe Perthe’s vascular test

Answer 3

Question 4

causes of gynaecomastia

Answer 4

• Liver cirrhosis due to alcoholism
  
  • Failure of liver so unable to metabolism oestrogen
• Bronchial carcinoma (rare paraneoplastic)
• Pituitary tumours (↑ prolactin)
• Hyperthyroidism
• Testicular tumours
• Renal failure
• Hypogonadism
• Drug related - esp. spironolactone

Question 5

causes of nipple discharge

Answer 5

• Physiological (60%)
• Duct ectasia
  
  • Benign condition, blocked duct
  • Cheesy water discharge, may be blood stained
• Intraductal papilloma
  
  • Blood discharge from single duct
• Epithelial hyperplasia
  
  • Occasionally blood stained, single duct
• Galactorrhoea
  
  • Pregnancy, high prolactin
• Carcinoma
  
  • Single duct discharge, Watery/serous/bloody

Question 6

what is the most common breast cancer?

Answer 6

ductal carcinoma

Question 7

is HER2 +ve a good or bad prognosticator?

Answer 7

bad

Question 8

is ER +ve a good or bad prognosticator?

Answer 8

good

Question 9

what are the signs of peripheral vascular disease?

Answer 9

• HAS LEGS
  
  • Haemosiderin deposition
  • Atrophie blanche
  • Swelling/oedema
  • Lipodermatosclerosis
  • Eczema (venous)
  • Gaiter region
  • stars (venous)

ulcers

Question 10

management of fibroadenoma

Answer 10

• conservative - most, safety next
• excision - patient request, large (> 3cm), complex, symptomatic

Question 11

describe screening for AAA

Answer 11

• men - offer in 65th year
• females - > 70 with RF (COPD, arterial disease, FHx, dyslipidaemia, HTN, smoking)

Question 12

describe the surveillance of AAA

Answer 12

• 3-4.4cm - yearly USS
• 4.5 - 5.4 - 3 monthly USS

Question 13

indication for elective AAA repair

Answer 13

• AAA > 5.5cm
• symptomatic
• asymptomatic > 4cm and growing 1cm/year or 5mm/6 months

Question 14

management of AAA (unruptured)

Answer 14

• reduce risk of rupture
  
  • smoking cessation
  • weight loss
  • HTN management
  • statin and aspirin
  • DVLA if > 6.5 (can’t drive till repair)
• monitoring
• surgical - open or EVAR

Question 15

EVAR vs OPen AAA repair

Answer 15

• similar long term, EVAR better short term
• EVAR has higher rate of re-intervention

Question 16

complications of open AAA repair

Answer 16

• haemorrhage, injury to structures, anesthetic
• early - pain, bleed, infection, seroma, blots, bowel ischaemia, renal impairment
• late - hernia, graft occlusion, impotence

Question 17

complications of EVAR repair of AAA

Answer 17

• conversion to open, anaesthetic risk
• early - pain, bleed, infection, seroma, clots, bowel ischaemia, AKI
• late - endoleak, migration, limb occlusion, impotence, reintervention

Question 18

causes of acute limb ischaemia

Answer 18

• thrombosis (40%)
• emboli (40%)
• aneurysms
• trauma
• graft/angioplasty
• vasospasm

Question 19

6 P’s of limb ischaemia

Answer 19

• Pain - constant, persistent
• Pulseless - ankle pulses absent
• Pallor (or cyanosis or mottling)
• Perishingly cold
• Paraesthesia or ↓ sensation or numbness
• Paralysis or power loss

Question 20

investigations in acute limb ischaemia

Answer 20

• Bedside
  
  • Examination of affected limb - neurovascular status
  • ABPI
  • ECG - assessment for AF
  • Handheld Doppler - assessment of peripheral pulses
• Bloods
  
  • VBG - monitor lactate
  • FBC, U&E, G&S, clotting
  • Glucose, lipids
  • Thrombophilia
• Imaging
  
  • Doppler USS
  • CT angiogram
  • Echocardiogram - ?AF (enlarged left atrium), ?IE

Question 21

acute initial management

Answer 21

• A-E assessment
• Duplex, angiogram (CTA, MRA or DSA)
• Referral to vascular surgeons + admission
• Heparin 500 IU IV stat
• Foot down to promote blood flow
• Determination of level and if salvagable
• Definitive management
• Control of reperfusion sequalae
• Anti-coagulation and control of embolic source as required

Question 22

what is the A-E for acute limb ischaemia

Answer 22

• A - ensure patent
• B - 100% oxygen, CXR (assess for signs of PE)
• C - IV access, 0.9% NaCl rehydration
  
  • Bloods - FBC, U&ES, glucose, cardiac enzymes, clotting, HbA1c, BNP, G&S
  • ECG - assess for AF
  • Urinary catheter to monitor fluid balance
• D
• E - opiate analgesia
  
  • Duplex, angiogram (CTA, MRA or DSA)

Question 23

definitive management of acute limb ischaemia

Answer 23

• No neurosensory deficit
  
  • early revascularisation
• Neurosensory deficit without limb staining/mottling → urgent CTA + revascularisation
  
  • If emboli → embolectomy (arteriotomy or balloon embolectomy, Fogarty catheter), 2nd - bypass or intra-op theombolysis
• If thrombosis
  
  • Bypass graft
• Intra-arterial thrombolysis
• Neurosensory deficit + limb staining/mottling
  
  • non-salvageable → palliation or amputation

Question 24

follow up/long term management of acute limb ischaemia

Answer 24

• Identify underlying cause/contributing factors if emboli
  
  • Clot sent for MC&S + histology
  • Image of proximal arteries
  • Echo - bubble, TOE
  • 24 hour tape - intermittent AF
  • Assess for hypercoagulability
• Risk reduction
  
  • Long term anti-coagulation or anti-platelet
• Statin

Question 25

types of aortic dissection

Answer 25

stanford * A - ascending aorta, most common * B - distal to left subclavian, descending

Question 26

RF for aortic dissection

Answer 26

* _HTN_ * aortic atherosclerosis * _CTD_ (EDS, SLE, Marfan's) * aortitis * trauma * iatrogenic * _cocaine/amphetamines_ * _valvular heart disease_

Question 27

management of aortic dissection