Leg pain, chest and back pain, shock CIS (Darrow) Flashcards
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 (atrial contraction into a non-compliant ventricle- can be caused by DM and HTN). Present BP is 130/60. He has a
“simian gait” (duck walk) 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?
Ankle/brachial index Femoral angiography Lumbar spine xray Lumbar MRI Venous doppler
Lumbar MRI
so spinal stenosis can look like PAD ***
A 45 y/o diabetic presents with burning, dorsal foot pain that is relieved by getting up or dangling the foot (gravity pulls blood into the foot). How do you know this is not diabetic neuropathy? How is the diagnosis made? What is the treatment?
tibial and pedal artery occlusion
DM neuropathy- not relieved with gravity-hanging leg
Diagnose by MRA
Treatment: Vein bypass to distal tibial or pedal arteries.
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 (DONT see dependent rubor). The pedal pulses are absent and the foot is cold. The heart rhythm is irregular What has happened?
acute arterial occlusion of a limb
a-fib potentially- and most likely had a clot?
which is true regarding the acute arterial occlusion of a limb
A. 50% of cardiac emboli go to the brain.
B. With loss of light touch, surgery can be deferred.
C. Before revascularization, NaCl should be administered.
D. Cause is never due to thrombosis.
E. Pedal pulse are not palpable.
Answer E. Pedal pulse are not palpable.
Which is true in regard to the above?
A. 50% of cardiac emboli go to the brain. no go to legs
B. With loss of light touch, surgery can be deferred. surgery should be done immediately
C. Before revascularization, NaCl should be administered NO, bicarb should be administered, get rid of lactic acid
D. Cause is never due to thrombosis No
what are the 6 p’s of arterial occlusion
Pain Pallor Paralysis Paresthesias Pulselessness Poikilothermia*- irregular
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 B. Carotid stroke C. Brain tumor symptoms D. Seizure disorder E. Diabetic neuropathy
know the D’s!!
A - vertebro-basilar TIA
have carotid system in front and vertebral basilar system in the back.
This patient is presenting with the D’s of VB TIA”S
Dizziness Diplopia Dysphagia Dysarthria Dysmetria Duration
Define carotid territory TIA… (3 things)
unilateral weakness or numbness on one side of body
aphasia
amaurosis fugax - transient vison loss
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):
mesenteric occlusion. ruptured appendix. diabetic neuropathy. pancreatic cancer. inflammatory bowel syndrome.
**mesenteric occlusion.
not tender, not really bloated, but they have severe pain and this is an emergency!! - they can get a bowel infarction very quickly
what is the treatment for mesenteric occlusion
Angioplasty and stent versus aorto-celiac or superior mesenteric bypass
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 (carotid pathology) 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 (polycythemic) WBC of 13,000 and platelets of 350,000 (Increased). 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?
Amaurosis fugax Abdominal enlargement Polycythemia Portal vein thrombosis Left sided numbness
she is having problems in both the arterial and venous systems***
Portal vein thrombosis
JAK 2 disease
what is a red clot
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
anything that causes stasis/ coagulation cascade activation
mostly venous clotting
white clot causes?
due to platelet aggregation
Caused by smoking,
hypertension, hyperlipidemia,
DM, cholesterol emboli. (atherosclerotic causes)
what causes venous AND arterial clotting
Heparin induced thrombocytopenia (HIT) (patient on heparin gets a clot)
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Myeloproliferative disease (especially JAK 2)–>
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
Know in general ==> HIT and Jak2
what is the treatment for an aortic aneurysm …
what is a significant aneurysm size… and what are they usually associated with?
Treatment–>
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
Truly significant aneurysm is 5-6 cm… and usually associated with coronary artery disease
BEFORE you repair this, make sure to repair the coronary arteries b/c they probably have CAD - so put in a stent in or something
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 (aortic insufficiency) at the base, with a 2/6 systolic murmur at the apex that lengthens with standing and shortens with handgrip (mitral valve–> mitral insufficiency). History is positive for a prior pneumothorax. Which would be an additional finding in this patient?
Posterior mid-thoracic machinery-murmur Aortic root dilation Pulseless left arm Hoarseness Paraplegia
***aortic root dilation - he has Marfan’s
Murmurs:
Hand grip (increase afterload)- should be louder, but in this case it wasn’t it was weaker!! This is not standard mitral regurg
With standing –> it lengthens/louder in this patient – less blood is filling usually with standing, and this murmur should quiet DOWN but It didn’t. so this is not standard mitral regurg
this is mitral valve prolapse (which is NOT standard mitral regurg) - this is typically seen in Marfan syndrome
Which is associated with a dissecting aortic aneurysm?
Dissection into the adventia Dull aching chest pain Anterior wall MI Systolic murmur Hypertension Paraplegia
what else can you see dissection in?
HTN and paraplegia
paraplegia- in 4% of people the vessels to the spinal cord come off the descending aorta!
it is dissecting into the media
Can also see dissection in pregnancy, bicuspid aortic valve (problems with aortic root), and coarctation.
–sharp tearing chest pain NOT Dull
– doesn’t give anterior wall MI –> inferior wall MI*** b/c the right coronary artery comes off next to the aortic valve
–Doesn’t give you a systolic murmur, it gives you a diastolic murmur- Aortic insufficiency ***
Know the symptoms of a dissecting ascending thoracic aortic aneurysm
versus a descending thoracic aortic aneurysm as given in Lange’s CMDT!
know it
ascending–> chest pain, sudden onset, radiating down back or into neck
a diastolic murmur may develop as a result of the dissection in the ascending aorta close to the aortic valve, causing valvular regurg, heart failure and tamponade
descending
syncope, hemiplagia, or paralysis of the lower extremities, peripheral pulses may be diminished or unequal
what is the medical treatment for an expanding or dissecting aortic aneursm…
surgery
or graft
what else produces mediastinal widening ?
Artifact – patient rotated. Chest X-ray is rotated and gives you pseudo-widening
Mediastinal Mass – T and B cell lymphoma, teratoma, thyroid, thymus = 4 Ts
Vessels – aortic aneurysm
Anthrax
peripheral artery aneurysm ….
presentations
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.- if they can’t feel light touch this prompts IMMEDIATE surgery
Which of the following predisposes to thrombophlebitis?
Tachycardia Exercise NSAIDs Vitamin E Trauma
Trauma
what is virchow’s triad
Hypercoagulability
Stasis
Trauma
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:
systemic hypercoagulability. Staphylococcus superinfection. pressure related to the pancreatic mass. related to IV catheters. related to chemotherapy.
systemic hypercoagulability.
every patient with cancer is prone to clots–> trousseau’s syndrome
what is trousseau’s syndrome
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). activation of platelets !!
whenever you have cancer you have hypercoaguable state
Thrombogenic cancers: gastric, esophageal, lung, pancreas, renal, ovarian, AML, non-Hodgkins lymphoma*.
if there is cancer, there is increased risk for clots - due to P and L selectins
cancers are sticky*** and that’s why metastases occurs
Bernard soulier
GpIb deficiency
results in bleeding
Glanzmann thrombasthenia
GpIIb-IIIa deficiency
results in bleeding
72 year old male with traumatic ulcer on his ankle?
venous insufficiency
venous ulcers….
History of trauma***, pregnancy, and varicose veins Medial malleolus*** is usually medial 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 normal
