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CV II Exam 3 > BV and Lymphatics > Flashcards

BV and Lymphatics Flashcards

1
Q

A 60 y/o male smoker presents with a 6 month history of impotence along with calf, thigh, and buttocks claudication. The femorals are not palpable.

A

Aorto-iliac occlusion

**Location of occlusion is important

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2
Q

Claudication

A

Pain caused by too little blood flow

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3
Q

Leriche’s syndrome

A

Aorto-iliac occlusion disease

Claudication, impotence, no femoral pulses

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4
Q

Treatment of occlusion disease

A 
Stop smoking and BP control
ASA, clopidogrel (anti-platelet)
Cilostazol (inhibit platelet aggregation and dilate vessels)
Pentoxifylline (antihemorrheological - change blood and vessel properties)
Ramipril
Statin (Rosuvastatin)
Stent
Bypass
Calf compression, angiogenesis
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5
Q

Dose of Cilostazol for occlusion disease

A

100 mg BID

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6
Q

Dose of Pentoxifylline for occlusion disease

A

400 mg BID

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7
Q

Reasoning for Ramipril use

A

Imbalance of NO and Ang II -> increase oxygen-free radicals -> increase adhesion molecules -> inflammatory response in vessels (increase SM proliferation and ECM production)

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8
Q

Protease Inhibitor antiplatelet drugs

A

Cilostazol and Pentoxifylline
Inhibit CAMP to 5’AMP
Decrease intracellular calcium

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9
Q

ASA mechanism

A

Decrease TXA2 levels

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10
Q

GP IIb/IIIa inhibitors

A

Decrease fibrinogen cross linking and direct binding

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11
Q

Thienopyridines

A

Block ADP feedback loop

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12
Q

P2Y12 signaling

A

Modulates thrombin generation

ADP feedback loop

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13
Q

A 60 y/o diabetic male presents with cramping pain in both calves with walking 2-4 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:

A

Superficial femoral

Provides branches to lower leg

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14
Q

Dependent rubor

A

Diminished circulation to extremity -> turns red when standing, will blanch when elevated

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15
Q

Block in profunda femoris

A

Claudication will occur earlier and higher on leg

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16
Q

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

A

DM - falsely high BP due to calcified vessels

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17
Q

Osler’s Sign

A

Pseudohypertension due to calcified vessels

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18
Q

Can you use ABI in diabetics with calcified vessels?

A

No, use wave form analysis instead

Occlusion will demonstrate diminished wave forms

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19
Q

Most potent predictor stent thrombosis

A

Calcification

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20
Q

Treatment for popliteal or femoral stenosis

A

Bypass

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21
Q

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.

A

Spinal stenosis

Can present like peripheral vascular disease

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22
Q

Imaging to detect spinal stenosis

A

Lumbar MRI

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23
Q

Simian gate

A

Waddling - not due to claudication

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24
Q

Improvement of back back with bending forward

A

Spinal stenosis

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25
Q

S4 heart sound

A

Strong atrial contraction into non-compliant ventricle

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26
Q

S4 seen frequently in patients with

A

DM and HTN

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27
Q

Tibial and pedal artery occlusion

A

A 45 y/o diabetic presents with burning, dorsal foot pain that is relieved by getting up or dangling the foot.

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28
Q

DM neuropathy vs Tibial/pedal occlusion

A

Occlusion feels relief of burning and pain by dangling the foot

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29
Q

Diagnose occlusion with

A

MRA - magnetic resonant angiography

Dorsalis pedis can sometimes be difficult to palpate even in normal patient but tibialis should always be present

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30
Q

A 35 y/o male from south Africa presents with sudden onset pain in 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.

A

A fib from thrown clot

A fib -> mural thrombi in left atria -> travels through arterial system -> stroke or leg clot

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31
Q

50% of cardiac emboli go to

A

Legs

Can also go to brain

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32
Q

Loss of light touch with arterial occlusion implies

A

Surgery should be immediate

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33
Q

Before revascularization what should be administered?

A

NaHCO3

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34
Q

6 Ps of acute arterial occlusion

A 
Pain 
Pallor
Paralysis
Paresthesias
Pulselessness
Poikilothermia (irregular temperature regulation)
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35
Q

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?

A

Vertebro-basilar TIA

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36
Q

The Ds of VB TIA

A 
**Dizziness
Diploplia
Dysphagia
Dysarthria
Dysmetria
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37
Q

TIA vs Stroke

A

TIA < 24 hrs

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38
Q

Lateral Medullary Syndrome

A 
Occlusion of vertebral or PICA
Ds
Numbness in contralateral arm and leg
Numbness in ipsilateral face
Horner's syndrome (CN 5)
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39
Q

Other LMS with Occlusion of vertebral or PICA symptoms

A

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.

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40
Q

Areas of medulla effected by LMS

A

Vestibular nerve
Restiform body
Ambiguous nucleus
Spinal tract of trigeminal nerve

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41
Q

Carotid territory TIA

A

Aphasias, unilateral weakness or numbness, and amaurosis fugax

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42
Q

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.

A

Mesenteric occlusion

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43
Q

Treatment for mesenteric occlusion

A

Angioplasty and stent

Bypass

44
Q

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 (TIA). She has been having abdominal pain after meals (abdominal angina) for the past 6 months. Hb is 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?

A

Portal vein thrombosis

BOTH venous and arterial involvement

45
Q

Red clot

A

Stasis clot on venous side
Caused by multiple thrombophilic and /or
Hypofibrinolytic factors, mostly inherited. Also
due to acquired risk factors.

46
Q

Inherited thrombophilic factors of red clot

A

Factor V Leiden, Prothrombin G20210A, ACLA

47
Q

Inherited hypofibrinolytic factors of red clot

A

4G/5G polymorphism of the plasminogen activator inhibitor-1 gene (PAI-1)

48
Q

Acquired risk factors of red clot

A

pregnancy, BCPs, high dose steroids, immobilization, surgery, and foreign bodies in the blood stream/catheters

49
Q

White clot

A

Arterial side

Starts with platelet aggravation

50
Q

Causes of white clot

A

Caused by smoking, hypertension, hyperlipidemia, DM, cholesterol emboli

51
Q

What causes both arterial and venous clotting

A

**Heparin induced thrombocytopenia (HIT)
Paroxysmal Nocturnal Hemoglobinuria (PNH)
*Myeloproliferative disease (especially JAK 2)
Polycythemia vera – like in this case
Anti Phospholipid Antibody Syndrome (APLAS)
Anti Cardiolipin Antibody Syndrome (ACLA)
Hyperhomocysteinemia
Thromboangitis obliterans (Buerger’s disease: vasculitis of arteries and veins).
Nephrotic syndrome (antithrombin III, protein S and C deficiency).
Right to left shunt
Popliteal artery aneurysm

52
Q

Key causes of both arterial and venous clotting to remember

A

HIT
Polycythemia vera
Thrombangitis obliterans (Buerger’s)
Nephrotic syndome

53
Q

Significant AAA

A

Greater than 5-6 cm

54
Q

Do you give anticoagulant for thrombosis in AAA?

A

No - increase risk of rupture

55
Q

Coronary surgery and AAA

A

Look at coronary arteries with AAA is detected

Coronary surgery before AAA repair to insure proper perfusion of heart during procedure

56
Q

Use of B blocker with AAA

A

Reduce pressure to reduce incidence of tearing

57
Q

Treatment for AAA

A

Labetolol 20 mg over 2 min IV, then 40 -80 mg q 10 min
Esmolol 0.5 mg/kg IV
Nitroprusside 50 mg in 1000 D5 at 0.5 mL/min
Surgical repair or endovascular graft

58
Q

A tall, thin 35 y/o male is found to have aortic insufficiency, mitral valve prolapse. History is positive for a prior pneumothorax.

A

Aortic root dilation

Marfans

59
Q

Spontaneous pneumothorax

A

Tall slender individuals

Marfans

60
Q

Aortic insufficiency murmur

A

Diastolic decresendo murmur at the base

61
Q

Mitral prolapse

A

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

Squatting decreases murmur

Increasing volume with increased afterload or increased venous return decreases the murmur

62
Q

Dissecting aorta involves dissection of:

A

Media

63
Q

Dissecting aortic aneurysm presents with:

A

Sharp tearing chest pain
Inferior MI (RCA nearby)
Diastolic murmur

64
Q

Dissecting aortic aneurysm associated with:

A

HTN (cause)

Paraplegia (descending aorta dissection cuts off supply to vertebral arteries supplying spinal cord)

65
Q

Dissection also associated with

A

Pregnancy, bicuspid aortic valve, and coarctation

66
Q

Expanding/dissection aortic aneurysm treatment

A

Beta blocker
Surgery for Type A
Surgery for Type B effecting perfusion to extremeties etc.
Surgery for AA greater than 5-6 cm

67
Q

Ascending aortic dissection

A

More chest pain

Upper extremities may be hypotensive

68
Q

Descending aortic dissection

A

More back and abdominal pain

Paraplegia

69
Q

Mediastinal widening

A

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

70
Q

70% Peripheral artery aneurysms

A

Popliteal artery

Can present with loss of distal pulse with acute leg or foot pain

71
Q

Risk with peripheral artery aneurysms

A

Thrombosis, embolization

72
Q

Surgery indication for peripheral artery aneurysm when:

A

Peripheral embolization, > 2cm in size, or a mural thrombus

73
Q

Surgery on peripheral artery aneurysm can be conservative when

A

Light touch sensation is still present

74
Q

Predisposition to thrombophlebitis

A

Trauma

75
Q

Virchow’s triad

A

Increased risk of thrombus

Blood (hypercoagulability)
Flow (stasis)
Vessels (trauma)

76
Q

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:

A

Cancer - systemic hypercoagulability

77
Q

Trousseau’s Syndrome

A

Cancers produce P and L selectins (glycoproteins and adhesion molecules) -> platelet rich microthrombi

Metastatic cells are sticky and move through blood making little clots

78
Q

Thrombogenic cancers

A

**Adenocarcinoma of lung

Gastric, esophageal, lung, pancreas, renal, ovarian, AML, non-Hodgkins lymphoma

79
Q

Manifestations of cancer associated thrombogenic cancers

A

Plegmasia cerulean dolens, DIC, TTP, marantic endo, superficial migratory thrombophlebitis,
and arterial thrombosis

80
Q

Absence of glycoproteins

A

Bleeding disorders

81
Q

72 y/o male with a traumatic ulcer on his ankle most likely has:

A

Venous insufficiency

82
Q

Venous ulcer

A 
History of trauma, pregnancy, and varicose veins
Medial malleolus
Superficial, irregular margins
Ruddy, beefy, fibrinous,  granulation
Edema
Dermatitis
Lipodermatosclerosis –indurated 
Hyperpigmentation
Moderate to heavy exudate
Cap refilling - < 3 sec (Normal)
ABI = 0.9 or greater
83
Q

Key findings of venous ulcer

A 
History of trauma
On medial malleolus
Irregular borders, beefy, red
Edema
Indurated
Hyperpigmentation
Exudate
84
Q

Arterial ulcer

A 
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
ABI = 0.5 or less
85
Q

Key findings of arterial ulcer

A 
Claudication
Site of pressure
Sharp borders
Grey or yellow
Hair loss, cold feet, no pulses
86
Q

Neuropathic ulcer

A 
History of *numbness
Common in *DM
Pressure site
Variable depth
Surrounding *callus
Cap refilling normal
ABI = normal
87
Q

Diabetic foot infections

A

More likely with positive probe to bone test, ulcer duration > 30 days, trauma , PVD, peripheral neuropathy, and RI

88
Q

Chronic leg ulcers associated with

A 
PAD
Venous insufficiency
DM 
Autoimmune diseases (Felty’s)
SS anemia
Erythema induratum/nodular 
              vasculitis/panniculitis
Fungal infection
89
Q

Septic Superficial Thrombophlebitis

A

Venous thrombosis associated with inflammation in the setting of bacteremia

90
Q

Septic Superficial Thrombophlebitis treatment

A

Vancomycin 15 mg/kg IV q 12 hrs

Ceftriaxone 1 gm IV q 24 hrs

91
Q

Phlegmasia Cerulean Dolens

A

Literally inflammatory (edematous), blue, and painful
Due to primary venous insufficiency with secondary arterial
insufficiency

92
Q

Causes of Phlegmasia Cerulean Dolens

A

**Cancer

Obesity, old age, immobilization, or other procoagulant conditions (Factor V Leiden)

93
Q

Phlegmasia Cerulean Dolens also causes

A

Hypovolemic shock

Massive fluid loss with decreased BP, or even vasodilatory shock from inflammatory mediators

94
Q

Phlegmasia Alba Dolens

A

Tissue not cyanotic and blue

Colateral veins allowing some drainage so that tissue ischemia does not occur

95
Q

Phlegmasia Cerulean Dolens treatment

A

Fluids
Anticoagulation
Investigate cancer

96
Q

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

A

Vena cava obstruction (superior)

97
Q

Causes of SVC obstruction

A 
Cancer
Chronic fibrotic mediastinitis (reaction to Histoplasmosis antigen, can happen with TB as well)
DVT from arm veins
Aortic arch aneurysm
Constrictive pericarditis
98
Q

Most common cause of SVC obstruction due to cancer

A

Non small cell lung cancer

Followed by small cell and lymphoma

99
Q

Pancoasts syndrome due to

A

NSCLC (especially squamous and adenocarcinoma)

100
Q

Is edema better in AM or PM

A

PM

Better venous flow with muscle use

101
Q

A 35 y/o black female presents with malaise, anorexia, sweating, chills, fever and throbbing pain in the left arm. There is warmth at the left antecubital fossa and a faint red streak is discovered over the dorsal left hand. The left axillary nodes are swollen. She denies any bites.

A

Cat scratch fever

102
Q

Cat-born diseases

A

Saliva:
Bartonella henselae, Pasteurella multocida, Rabies, Capnocytophagia, Tularemia
(**Gm Neg intracellular bacteria)

Fecal:
Toxoplasma gondii, Cryptosporidium, Salmonella, Campylobacter, Ancyclostoma braziliense (Hookworm), Toxacara cati (Round worm)
Aerosol:
Coxiella burnetti

Tick or flea bites:
Lyme disease, Ehrlichiosis, Babesiosis, Yersinia pestis

Urine:
Leptospirosis

Direct contact:
Sporothrix schenckii, Microsporum canis (Ringworm)

103
Q

Lymphedema

A

Pitting edema without ulcers, varicose veins or stasis pigmentation

Fibroses

104
Q

Milroy’s disease

A

Congenital lymphedema with break in the VEGFR 3 gene

105
Q

Stewart-Treves syndrome

A

Actually a hemangiosarcoma rather than a lymphangiosarcoma due to local immunodeficiency

CV II Exam 3 (13 decks)

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