Cardio. NBME 10 and 11, mehl. Cardio bullets: VESSELS Flashcards
NBME 10. 24Q. venous vs arterial pathology on legs.
57y.o + smoking 40 years + The left ankle brachial index is 0.75 (N>1). truck driver. Shown photo: ulcer in medial aspect of the distal leg (blauzdos vidinej daly prie sanario). Dx?
Venous insufficiency
ulcer: medial malleolus
Kadangi ABI 0,75 = simultaneous perif artery disease. but ulcer is characteristic for venous
NBME 10. 24Q. …. a common cause of nonhealing ulcers on the lower extremities. ?
Venous insufficiency
NBME 10. 24Q.
In a healthy vascular system, return of venous blood from the legs is aided by?
muscle contraction which acts as a mechanical pump, along with valves preventing retrograde flow of blood.
NBME 10. 24Q. in what cases decr. muscle contractions?
In individuals who sit or stand for prolonged periods of time (eg, truck drivers, as in this example), results in chronically increased venous pressure (venous hypertension)
NBME 10. 24Q. venous insufficiency manifests with? CP
leg swelling, leg heaviness, venous varicosities, venous ulcers, and bronze discoloration of the leg (bronze - result of hemosiderin deposition from extravasated red blood cells, woody induration from chronic edema, and dilated superficial veins).
NBME 10. 24Q. venous ulcers when heals?
Venous ulcers will heal only when the underlying venous insufficiency is addressed.
NBME 10. 24Q. kitas ats. Perif. artery disease. definition?
abnormally diminished flow of blood to the extremities, which carries the potential for ischemia and necrosis of the extremity
NBME 10. 24Q. kitas ats. perif artery disease: where ulcers?
Nonhealing ulcers tend to occur at the sites most distal from the blood supply and thus the most susceptible to ischemia, such as the distal digits.
!!NBME 10. 24Q. kitas ats.
Venous insufficiency and peripheral arterial disease often occur simultaneously, as suggested in this patient by the abnormal left ankle brachial index. However, the cause of the pictured ulcer is more likely venous insufficiency given its location over the medial malleolus and other cutaneous changes of venous insufficiency.
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NBME 11. 61Q. 67y.o man + smoked for 40 yo. Came because of pain that begins after he walks approximately 50 feet; it improves if he stops walking but returns when he tries to move again. BP normal, KMI 33. What need to evaluate at this time?
Abdominal aortic aneurysm
Ultrasonography to screen for AAA in men aged 65 to 75 years who have a history of tobacco use.
In addition to continuing his pharmacologic regimen, controlling hypertension, and counseling on weight management and tobacco cessation, the patient should be evaluated for an abdominal aortic aneurysm (AAA) at this time.
NBME 11. 117Q.
77 y/o womna + 3d ago underwent open fixation of a right hip fracture + has progressive edema of the right lower extremity. Temp. 38.0°C, vitals normal. There is 3+ pitting edema of the right lower extremity from the foot to the hip. Which of the following is the most likely set of findings on venous duplex ultrasonography?
Superficial veins - normal
Deep veins - obstructed
NBME 11. 117Q. A variety of patient-related and surgery-related factors contribute to the formation of DVTs including hypercoagulability or malignancy, surgical technique, and the degree of immobilization following surgery.
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NBME 11. 117Q.
Knee and hip arthroplasty are considered high-risk for DVT because prolonged immobilization is typically required postoperatively. Patients undergoing major surgery should be given prophylaxis to prevent the development of DVT and VTE. Subcutaneous low-molecular-weight heparin, such as enoxaparin, is the preferred first-line agent because of its high efficacy, ease of dosing, affordability, and low risk for major bleeding.
However, despite these measures, DVTs can still develop, and they most commonly present with erythema, warmth, and edema in the affected extremity. Diagnosis is made with duplex ultrasonography, which will most likely show obstruction of the deep veins with normal superficial veins.
NBME 11. 117Q. DVT Dx how is made?
Duplex ultrasonography, which will most likely show obstruction of the deep veins with normal superficial veins.
NBME 11. 131Q 17 boy + was thrown through a window during an altercation + has 4 × 4-cm glass shard protrudes from the right upper extremity 2 cm proximal to the medial epicondyle; the extremity is cool and pale, and radial and ulnar pulses are not palpable. NEXT STEP?
Operative wound exploration
Wrong - angiography, Ug
NBME 11. 131Q glass in artery.
After a penetrating injury to an extremity, evaluation of bones and joints, soft tissue, vasculature, and peripheral nerves should be performed. what involves vascular assessment?
Vascular assessment involves evaluation of skin color, temperature, capillary refill, and pulse.
NBME 11. 131Q glass in artery. In a patient with an obvious vascular injury such as with asymmetry or absence of distal pulses, emergent exploration and management in the operating room is necessary.
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NBME 11. 131Q glass in artery. when need imaging?
Vascular injuries can be more subtle, such as with differences in systolic blood pressure between upper extremities in patients with joint dislocations or fractures. In these cases of suspected vascular injury, vascular imaging such as with CT angiography can aid diagnosis.
However in cases of clear injury, operative exploration and repair should not be delayed.
NBME 11. 154Q. 42y.o women + 2 hours after the onset of pain and numbness in her left arm; she is having difficulty moving her arm. Two weeks ago, she was diagnosed with right popliteal venous thrombosis, and treatment with heparin and warfarin was begun. The left upper extremity is pale and cool; sensation to touch is decreased in a glove distribution distal to the mid forearm. Strength of the intrinsic muscles of the left hand is 2/5. Her prothrombin time is 14 sec (INR=1.3). An uncomplicated brachial embolectomy is performed. Which of the following is most likely to confirm the diagnosis?
Transesophageal echocardiography
the most likely cause of her acute limb ischemia is paradoxical embolism through a right- to-left intracardiac or intrapulmonary shunt, and echocardiography is more likely to confirm the diagnosis (not CT angio - for pulmonary embolism).
Paradoxical emboli may traverse through a patent foramen ovale, atrial septal defect, ventricular septal defect, or pulmonary arteriovenous malformation.
NBME 11. 154Q. Arterial thromboembolism is the most common cause of acute upper extremity limb ischemia.
Thrombus in heart –> arm –> arm ischemia.
Transesophageal echocardiography is the best diagnostic test to confirm the diagnosis
NBME 10. 112Q.
25-year-old man + right calf pain that began after he played in a soccer match. The pain is worse with walking and resolves with rest or acetaminophen therapy.
There is no family history of serious illness. The patient traveled outside the USA by plane 4 months ago. He drinks 48 oz of beer weekly. He does not smoke cigarettes or use illicit drugs. Vitals normal. Ecchymoses over the anterior and lateral aspects of the right calf. The calves are symmetric in size, and there is no warmth. The right lower extremity is diffusely tender to deep palpation below the knee. D-dimer concentration is less than 0.2 μg/mL (N<0.5) by ELISA. BEST NEXT STEP?
No further testing is indicated
NBME 10. 112Q. DVT + WELLS.
Familiarity with the Wells criteria is useful for the clinician to determine the likelihood of the presence of??
DVT) and can reduce the pursuit of unnecessary diagnostic testing.
NBME 10. 112Q. DVT + WELLS.
Wells criteria stratify patients into those with a low risk or a high risk for DVT, based on the presence of the following factors:??
Active cancer within 6 months
recently bedridden for longer than 3 days or major surgery within 12 weeks
calf swelling greater than 3 cm
collateral superficial veins
localized tenderness along the deep venous system
pitting edema of the affected leg
paralysis or paresis of the affected leg or recent plaster casting
previous DVT
and absence of an alternate diagnosis.
NBME 10. 112Q. DVT + WELLS.
Patients with a score of less than 2 are considered unlikely to have DVT. In these patients, the presence of a negative D-dimer test is sufficient to exclude the possibility of DVT and obviates the need for further workup.
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NBME 10. 112Q. DVT + WELLS.
In patients with suspected DVT and a score greater than 2, what can be done?
ultrasonography can be performed to confirm the presence of DVT.
NBME 10. 144Q.
27y/o + 50 minutes after he sustained a gunshot wound to his right leg + pressure dressings. Vitals pulse is 100/min and regular, RR 18/min, BP 100/85. Examination shows a single gunshot entry and exit wound in the right thigh with moderate oozing of bright red and dark blood but no pulsatile bleeding. The mid thigh is edematous. The right femoral pulse is palpable; no popliteal or pedal pulses are palpable. The right ankle brachial index is 0.5 (N>1) at the dorsalis pedis. In addition to intravenous fluid administration, which of the following is the most appropriate next step in management?
Intraoperative angiography
The patient has suffered a severe lower extremity injury secondary to penetrating trauma with evidence of vascular injury and hemodynamic instability.
In this case, the report of bright red bleeding at the scene, an edematous thigh, and the absence of popliteal and pedal pulses with a severely decreased ankle-brachial index argue for a direct arterial injury.
The presence of tachycardia and hypotension with continued oozing of blood are concerning for current active hemorrhage.
NBME 10. 144Q. arterial injury.
The patient is at risk for acute limb ischemia, loss of the extremity, and hemorrhagic shock, and he should undergo immediate evaluation in the operating room with intraoperative angiography to identify and repair the site of vascular injury.
Penetrating and blunt trauma can compromise blood flow because of direct mechanical disruption of the vessel, thrombosis or thromboembolism, or development of compartment syndrome
NBME 10. 144Q. arterial injury. Acute limb ischemia is a medical emergency characterized by?
Pain, pallor, absent distal pulses, poikilothermia, paresthesia, and paralysis as injury to the limb progresses.
Unstable patients should be evaluated in the operating room for timely diagnosis and intervention.
NBME 10. 144Q. arterial injury. kiti ats.
CT scan of the right lower extremity (Choice B) would be appropriate to evaluate for injury to bone and soft tissue and for retained bullet fragments if there was minimal concern for vascular injury or active bleeding. An unstable patient with signs of acute limb ischemia should bypass the radiology department for the operating room.
Intravenous administration of heparin (Choice E) is contraindicated in this patient with a traumatic penetrating injury to the extremity and active bleeding. In other clinical situations, arterial thromboembolic disease is on the differential for acute limb ischemia and anticoagulation may be warranted.
NBME 10. 168Q.
18 y/o + involved in a high-speed motor vehicle collision in which he was the unrestrained driver + ulse is 100/min, respirations are 16/min, and blood pressure is 105/60 mm Hg. Pulse oximetry on an FIO2 of 1.0 shows an oxygen saturation of 100%. GCS 3. Xray - wide mediastinum. Femoral pulses are 1+ bilaterally. Inserted catheters + iv fluids. next step?
CT angiography of the chest
NBME 10. 168Q. traumatic dissection.
The gold standard of diagnosis involves CT angiography of the aorta; however, hypotensive patients may be too unstable to tolerate a CT scan. A chest x-ray can be obtained which may show a widened mediastinum as in this case. CT angiography of the chest can differentiate types of blunt aortic injury, including aortic dissection, aortic rupture, or pseudoaneurysm.
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NBME 10. 168Q. traumatic dissection. repair?
Repair of traumatic dissection of the aorta can be done via open repair or endovascular repair.
NBME 10. 168Q. traumatic dissection. gold standard Dx?
CT angiography of the chest
