Vascular and breast Flashcards
What looking for at end of bed vascular
Amputations
Cyanosis
Dressings
Scars
Walking aids
What looking for in inspection of limb vascular
Vascular disease signs
- Pallor
- Hair
- Cyanosis
- Gangrene
- Ulcers
- Xanthomata
- scars for bypass
- muscle wasting
- rubor
Risk factor signs
- tar staining
- xanthomata
What does finger tip necrosis indicate
Buergers disease
How long hold down in CRT
5 seconds
Causes of radial radial delay
Aortic coarctation
Subclavian artery stenosis from cervical rib etc
Aortic dissection
Which pulses assess in upper limb in vasc exams
Radial
Brachial
Where listen for aortic bruits
2cm superior to ublilicus
Where does aorta bifurcate
L4
What signs on examination indicate chronic PAD as opposed to acute
Hair loss
Muscle wasting
What is rubor
Blushing of the skin
Pulses felt in lower limb vascular exam
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Where is femoral pulse felt
Halfway between ASIS and pubic tubercle
How do buergers test
Lift both legs to 45 degrees for 2 minutes then assess if pallor
Angle at which get pallor is buergers angle
What is buergers angle in healthy person vs severe PAD
Healthy should remain pink even at 90
Severe is less than 20
What ask for post vascular exam
BP in both arms sitting and standing
Cardiovascular exam
ABPI
Neuro exams if any defects detected
What looking for on examination of breast
Scars
Asymmetry
Skin changes
Nipple abnormalities
Visible lumps
Skin changes on breast
Diffuse erythema
Scaling of nipple or areola
Peau d’orange
Puckering
What is puckering of breast and what causes
Indrawn skin indicative of malignancy invading liagments contracting skin
Causes of nipple inversion
Normal findings typically- congenital or weight loss
Duct ectasia
Cacner
Infections- mastitis or abscess
What does peau d orange indicate
Inflammatory breast disease
Causes of prurulent nipple discharge
Abscsess
Mastitis
ABPI values meaning
less than 0.5= immediate referral
0.6-0.8= PAD
0.9-1.1= normal
>1.1= stiff vessels from DM, RA, vasculitis, old, CKD
Management of intermittent claudication
Clopidogrel
Atorvastatin
Graded exercise regime
2nd line
- revascularisation via endovascular surgery with angioplasty, or surgically with endarterectomy or bypass
- if decline then naftridrofuryl oxalate (serotonin anatagonist)
Management of critical limb ischaemia
Urgent vascular referral
Analgesia
Urgent revascularisation
- endovascular angioplasty
- endarterectomy
- bypass
- amputation
What differentiates between doing endovascular versus surgical revascularisation on PAD
Endovascular indications
- stenosis under 10cm
- only 1 lesion
- around the iliac area
Surgical indications
- over 10cm
- multifocal lesions
- common femoral and more distally
Varicose veins management
Primary care conservatively with
- emollients
- compression stockings
- lose weight
- leg elevation
If bleeding regularly, bothersome, venous insufficiency signs, thrombophlebitis then can refer for surgical intervention
- foam sclerotherapy
- endothermal ablation
- surgical removal
Thrombophlebitis management
Want to refer to rule out DVT with USS if strong clinical suspicion or in long saphenous vein
- if not then options include topical or oral NSAIDs, compression stockings to reduce DVT progression or consider LMWH
Venous ulcer management
Measure ABPI to ensure can use compressoin therapy
Clean then compression therapy
Can consider adding pentoxifylline alongside which helps healing
Consider referral to tissue viability nurses for wound cleaning etc
Features of venous ulcers
In gaiter area
Rolled edges
Bleed easily
Haemosederin deposition
Lipodermatosclerosis
Atrophie blanche (hypopigmentation)
Wine bottle deformity of calf
Acute limb ischaemia management
IV morphine
IV UFH if long wait
Surgical
- percutaneous thrombolysis
- thrombectomy
- emolectomy
- bypass
- amputation
Breast mass causes
Infectious
- abscess
- periductal abscess
Cystic
- simple breast cysts
- fibrocystic disease
Solid
- malignancy
- fibroadenoma
- phyllodes
- intraductal papilloma
- duct ectasia
- galactocele
Breast cancer urgent referrals
Over 30 with unexplained lump
Over 50 with discharge, retraction or any other change in 1 breast
Skin changes indicative of cancer
Lump in axilla if over 30
Breast spinal chord mets management
Dexamethasone and admit for urgent MRI spine
Consider need for hypercalcaemia management will fluids
Management will depend on comorbidities and neurological dysfunction but could include
- opioids
- bisphosphonates
- radiotherapy
- surgical decompression
