Vascular on call Flashcards
83 year old female presents to vascular ward after referral from A+E for 3/7 of increasing R foot erythema, pain and tenderness. She has a PMH of T2DM and is on metformin and linagliptin. She is clinically afebrile, BP 145/95, HR 75bpm.
You clinically examine her.
What are the clinical features of DFI?
How do you distinguish between mild, moderate, severe?
History taking-what questions to ask in DFI Hx? Clinical examination-what is important to look out for?
that you need to look out for?
What are the clinical features of a severe active foot infection?
What investigations would you do?
Diabetic foot infection
-present with erythema, warmth, pain and tenderness
-may have ulceration
Mild vs moderate vs severe infection
Mild: systemically well with erythema, warmth, pain and tenderness; ulceration with redness within 2cm
Moderate: systemically well + one or more of the following features: osteomyelitis, muscle/tendon/joint infection, lymphaginitis, abscess, spread beyond superficial fascia, ulceration with redness>2cm
Severe: systemically unwell with septic features-fever, rigors, tachycardia, hypotension-> escalate to Reg
Hx taking:
- usual Q
-intermittent claudication/rest pain/night pain
-fever rigors
O/E:
-does patient look systemically well from end of bedside?
-examination of foot: ulceration/gangrene/abscess/local infectioni or spread?
-temperature , cap refill
-sensation
-palpation of DP/PT and other pulses
Active foot infection
-wet gangrene/ abscess/pus/ osteomyelitis/muscle or tendon or joint infection/lymphaginitic spread
What are the osteomyelitis X ray features: early-> later?
Osteomyelitis
-infection of bone
Early stages:
-soft tissue swelling
-effusion
Later:
-bony destruction like trabecular architecture
-periostitis: inflammation of periosteum around bones
-focal osteopenia
What is the antimicrobial treatment for mild/moderate/severe DFI?
65M presents to A&E with severe pain in his R leg even at rest and purple discoloration in his toes. He has a PMHx of hypertension and T2DM. O/E R leg is pale and cold and peripheral pulses are not palpable. You are asked by A&E registrar to r/v patient.
What is chronic limb ischemia and risk factors?
What is Fontaine classification of limb ischemia I-IV? What are the clinical features and how would you examine patient?
What investigations would you do?
What is the medical vs surgical management of patient?
When is bypass grafting preferred over angioplasty */- stenting?
Chronic limb ischemia
-peripheral arterial disease mainly affecting lower limbs. However, may affect upper limb and gluteals as well.
-main demographic >65M
-RF: poorly controlled DM, HTN, smoking, hyperlipidemia, CVA/ACS, obesity, sedentary lifestyle
Clinical features (depends on severity)
-leg cramps that go away with rest in a few min
-ischaemic rest pain in severe disease; arterial ulcers
-gangrene in more severe disease
Fontaine classification of CLI:
I-asymptomatic
II-intermittent claudication
III- ischemic rest pain
IV-gangrene
Questions to ask: how far can you walk before you get pain in ur legs? (Claudication distance) how long does it take to go away?
O/E
General appearance-pale/ presence of ulcers /gangrene (do they look wet? Infected)
Temperature , cap refill
Check pulses with Doppler
Check for sensation
Buerger’s test-raise both legs until point when you see pallor for 2-3 min. <20 degrees indicated critical limb ischemia
ABPI
Other investigations for cardiovascular risk factors-ECG, lipid profile + HbA1c
Imaging:
-Doppler ultrasound; followed by CT angio or MR Angio
Management
Medical:
-control of vascular risk factors: smoking cessation, weight loss, antihypertensives, optimise diabetic control
Atorvastatin 80mg + clopidogrel 75mg OD
Surgery:
-bypass grafting for diffuse disease or younger patients
-balloon angioplasty+/- stenting for focal occlusion
-amputation for irreversible ischemia
What are the 3 features that define critical limb ischemia
- Ischaemic rest pain often requiring opioid analgesia for > 2weeks
- ABPI<0.5
- Ischaemic feature like gangrene
How do you determine difference between arterial and venous ulcer?
Arterial ulcer:
-painful
-deep
-punched out well defined edges
-may have black eschar
Venous ulcer:
-not painful
-shallow
-irregular poorly defined edges
-sloughy
What is the difference between acute and chronic limb ischemia?
Acute <2weeks often presenting w severe leg pain within a few hours
Patient has ABPI of 0.6. How would you classify this in terms of severity?
What do these ABPI values mean?
>0.9
0.8-0.9
0.5-0.8
<0.5
Moderate (0.5-0.8)
> 0.9: normal
0.8-0.9: mild disease
0.5-0.8: moderate
<0.5: severe
