Vascular

Question 1

List the risk factors for artherosclerosis

Answer 1

• old age
• male gender
• family history of cardiovascular disease
• high LDL, low HDL
• hypertension
• smoking
• diabetes

Question 2

List the complications of artherosclerosis

Answer 2

• plaque stenosis lead to occlusion of artery
• plaque hemorrhage and rupture -> thrombosis and embolization
• aneurysm formation
• calcification of blood vessels
• plaque erosion and ulceration

Question 3

Discuss the risk factors and pathogenesis of abdominal aortic aneurysm

Answer 3

- Is a localized dilatation of the artery involving all three layers at least 1.5x its expected diameter
Risk Factors
- age >65
- 4M:1F
- artherosclerotic risk factors
- family history
Pathophysiology
- true aortic aneurysm from degenerative artherosclerotic disease
- 90% are infrarenal

Question 4

Discuss the presentation and management of AAA

Answer 4

Screening abdominal ultrasound
- male age 65-75
- male age >50 with family history of AAA
- female age 65 with positive cardiovascular disease and family history
Presentaton
- asymptomatic
- rupture triad of abdominal pain, hypotension, and pulsatile abdominal mass
Investigation
- abdominal CT
Monitoring Guidelines
- <3cm repeat in 3-5 years
- 3-3.4 repeat in 3 years
- 3.5-3.9 repeat in 2 years
- 4-4.5 repeat in 1 year
- >4.5 repeat in 6 months
Indications for surgery
- sympatomatic
- rapid expansion (>0.5cm in 6 months or >1cm per year)
- >5.5 cm
- >2 times normal lumen size
- rupture

Question 5

Discuss the presentation and management of peripheral arterial disease

Answer 5

Presentation
- claudication which is pain with exertion relieved with 2-5 minutes of rest without postural change
- reproducible pain
- critical ischemia when have ulceration and gangrene
- arterial insufficiency: thin, shiny, hairless, pale, cool, red skin with painful and rapidly developing peripheral ulcer
- absent pulses
- pallor on elevation with rubor on dependency
- ABI <0.95 (PAD), 0.5-0.8 (symptomatic), <0.4 (critical)
Investigation
- doppler ultrasound
- CT arteriography
Management
- lifestyle modification with exercise
- anti-platelets
- angioplasty, endarectomy, bypass or amputation if severe

Question 6

Discuss the presentation and management of acute limb ischemia

Answer 6

Presentation
- Pallor, polar, pulselessness, pain, paralysis, paresthesia
- ABI <0.4
Investigation
- ECG and echocardiogram
- CT angiography
Management
- IV heparin bolus and infusion
- revascularization

Question 7

List the findings of a venous insufficiency ulcer

Answer 7

Pathophysiology
- valve incompetence leading to venous hypertension
Presentation
- superifical, irregular ulcer with granulation tissue over medial malleoulus
- moderately painful
- brown discoloration of skin
- dependent edema
- varicose veins
- normal pulses
Management
- compression stockings at 30mmHg
- moist dressing

Question 8

List the findings of a arterial insufficiency ulcer

Answer 8

Presentation
- deep, white, necrotic, punched out ulcer
- extremely painful that decreases with dependency
- decreased pulses
- shiny, hairless skin
Management
- improve blood supply

Question 9

List the findings of a diabetic foot ulcer

Answer 9

Presentation

• ulcer at pressure point
• necrotic, irregular, punched out ulcer with hyperkeratotic skin border
• painless

Question 10

Discuss the presentation and management of a malignant skin ulcer

Answer 10

Presentation
- unusual site with fungating ulcer
- dry, scaly skin with white translucent scale
- unresponsive to normal treatment
Investigation
- skin biopsy
Management
- surgical excision

Question 11

Discuss the presentation and management of lymphedema

Answer 11

Presentation
- heaviness, tightness in calf
- ipsilateral swelling with pitting
- progress proximal to distal and improve with limb elevation
Management
- treat malignancy
- compression bandage

Question 12

Discuss the presentation and management of post-phlebitic syndrome

Answer 12

Presentation
- complication of DVT where have valve incompetence leading to transudation of fluid with subsequent edema and ulceration
- venous insufficiency symptoms
Management
- compressive bandage and skin care

Question 13

Discuss the presentation and management of varicose veins

Answer 13

• distention of superficial veins due to incompetent valves in deep, superficial or perforator venous system
  Risk Factors
• female
• elderly
• obesity
• pregnancy and OCP use
• long hours of standing
  Presentation
• lower extremity aching made worse with prolonged standing
• long, dilated tortuous superficial veins
• Brodie-Trendelenberg where patient raise leg and tourniquet applied -> when stand incompetent valve have filling from top down
  Management
• compression stocking
• operative for symptomatic, skin changes, cosmesis