Vascular Problems - Dawes and Ramchandra

Question 1

Likely causes of DVT

Answer 1

Virchow's triad 
- Stasis, endothelium, blood constituents 
Stasis 
- Long haul flight, obese? 
Personal / family history 
- Lupus anticoagulant, antiphospholipid Abs, Protein C and S, antithrombin III, Fator V lieden.
- Previous DVT 
Tumour history 
Drugs

Question 2

Why is the leg swollen?

Answer 2

Occluded deep limb veins
Impaired venous return
Increased hydrostatic pressure

Question 3

Why is the leg red and hot?

Answer 3

Venous clot = dynamic process 
Large clots can produce increase temp 
Inflammation ++ 
WBC activation 
Cytokine release

Question 4

Treatment options - DVT

Answer 4

Anticoagulation 
- Enoxaparin: home inpatient 
- Warfarin: maintain INR 2-3, duration 3-6 months 
- Lifelong if 2nd VTE event 
Dabigitran alternative to warfarin 
Analgesia 
- paracetamol
- elevate leg

Question 5

Treatment options - PE

Answer 5

Similar to DVT 
- LMWH 
- Warfarin (longer duration - 6 months if first event) 
- Drug interacitons 
Severe 
- thrombolysis

Question 6

How do you know when to treat with anticoagulation in AF?

Answer 6

CHADS-VAS score, if greater than or equal to 2 give warfarin
Assess HASBLED score, if greater than or equal to 3 then don’t give warfarin

Question 7

Anticoagulation time frame for DVT vs AF

Answer 7

DVT / PE 
- Urgent 
- Usually initially as inpatient commencing with LMWH 
AF 
- Not so time sensitive 
- Usually as outpatient 
- No LMWH needed 
- Warfarin vs dabigatran

Question 8

Diabetes diagnoses: symptomatic vs no symptoms

Answer 8

Symptomatic 
- random plasma glucose > 11.1 
- Fasting plasma glucose > 7
HbA1c > 48mmol/mol 
No symptoms 
- 2 abnormal blood tests

Question 9

Causes for unhealthy overweight patient to have reduced ankle pulses

Answer 9

Dorsalis pedis, posterior tibial

Peripheral vascular disease (occlusion, atheroma)

Question 10

Cause of intermittent calf pain

Answer 10

• Intermittent claudication
• Ischaemic muscles (lactate/ inflammation)
• collateral development (long term)
• Pre- conditioning (angina to the store but not on the way home)

Question 11

Loss of feeling/ tingling / burning in the feet

Answer 11

diabetic nephropathy

• chronic peripheral
• acute peripheral nephritis

Question 12

Feels faint / sweaty after meal

Answer 12

Faint on standing

• Autonomic neuropathy
• Postural hypotension
• post gustatory sweating

Question 13

Dry and cracked hands and feet

Answer 13

• ischaemic
• poor skin growth
• increased risk infection

Question 14

patient advice and treatment

Answer 14

Analgesia 
Good glycemic control 
Vascular risk factor control 
- stop smoking 
- aspirin 
- BP management 
- cholesterol management 
- exercise diet weight

Question 15

Why does a patient with GI bleeding have a reduced Hb, and what does this suggest about the extent and time course of her blood loss?

Answer 15

long time course of blood loss, initially you don’t have decrease in Hb because you’re also losing volume of blood? so relatively the same? but because Hb is low there must have been a translocation of fluid from the intersitium to maintain blood volume.

Question 16

If a patient has has symptoms of GI bleed and BP 130/50, HR 130Bpm and Hb = 45g/L
Do you think the patients CO and TPR are higher or lower than normal? What evidence supports this?

Answer 16

If MAP is maintained and CO (maybe 3x to maintain oxygen perfusion) is elevated then TPR has to be decreased because if TPR elevated then MAP must also be elevated.
Some sympathetic stimulation mainly to heart to increase CO and to periphery to try and re direct blood flow form the periphery to the internal sites. Probably a drive to increase SNA to internal organs, but in the end, metabolic vasodilatation wins out over the sympathetic stimulation to the vascular beds.

Question 17

Why would the above patient be listless and cold?

Answer 17

Not as much blood flow to the periphery, this suggests TPR and peripheral vessels are constricted

Question 18

Appropriate treatment for the patient?

Answer 18

Address the cause of bleeding –> upper and lower GI endoscopy. give acute blood transfusion to increase their Hb.

Question 19

Significant of MCV on smear if long term blood loss

Answer 19

reticulocytes would only be elevated if you’ve started someone on iron supplementation. But reticulocytes are quite big so if you’ve lots of reticulocytes and a few mature red cells this can raise the MCV value. In this case you need to look at red cell distribution