Week 8 formative quiz questions

Question 1

Intermittent claudications is associated with narrowing of the arterial supply typically in the upper limb.

Answer 1

False – this typically happens in the lower limbs. Narrowing of the arteries, like in atherosclerosis, causes a mismatch between oxygen demand and supply. This leads to an anaerobic metabolism and a build up of lactic acid and as a result causes the pain.

Question 2

A stroke can be caused by trauma.

Answer 2

True - The internal carotid artery supplies the anterior circulation to the brain. In traumatic dissection a tear in the wall of the artery occurs leading to a false lumen, this can narrow or occlude the carotid artery leading to a stroke.

Question 3

The pain classically associated with aortic regurgitation is severe central crushing chest pain radiating to the left arm.

Answer 3

False - It is classically severe tearing chest pain radiating to the back.

Question 4

An aneurysm is an abnormal dilatation of a blood vessel.

Answer 4

True - An aneurysm is an abnormal widening of a blood vessel.

Question 5

Untreated syphilis can result in an aortic aneurysm.

Answer 5

True - Untreated syphilis can result in severe complications such as an aortic aneurysm, aortic regurgitation and neurological complications.

Question 6

The treatment of varicose veins is always surgery.

Answer 6

False - Management may include conservative management and compression. Another example includes injection sclerotherapy.

Question 7

Smoking is a risk factor in the development of peripheral arterial disease.

Answer 7

True – as is the case with all cardiovascular disease, smoking is a huge risk factor for the development of peripheral arterial disease. It has been shown to be the single most powerful risk factor associated with the aetiology and progression of peripheral arterial disease. Smoking cessation should be advised in these patients.

Question 8

A false aneurysm occurs due to weakness and dilatation of all 3 layers of a vessel.

Answer 8

False - This is the case in a true aneurysm. A false aneurysm involves a collection of blood/haematoma which is either contained by the adventitial layer or the surrounding tissue.

Question 9

A varicose vein is defined as a tortuous and dilated deep vein.

Answer 9

False - A varicose vein is defined as a tortuous and dilated SUPERFICIAL vein.

Question 10

50% of diabetic foot ulcers require amputation.

Answer 10

False - only 20% of diabetic foot ulcers require amputation. 50% of diabetic foot ulcers become infected.

Question 11

Abdominal aortic aneurysms are more common in females.

Answer 11

False - These are more common in males. Other risk factors include increasing age, smoking, hypertension, peripheral vascular disease, ischaemic heart disease, genetics and connective tissue conditions such as Marfan’s and Ehlers Danlos syndrome.

Question 12

Open surgery is the preferred option for treating varicose veins.

Answer 12

False. Endovenous treatment and ultrasound guided foam sclerotherapy are 1st and 2nd line options. Open surgery is now 3rd line option for treatment of varicose veins.

Question 13

All men aged 65 are invited to undergo an Ultrasound scan to screen for Abdominal Aortic Aneurysm.

Answer 13

True - If screening detects an aneurysm they are followed up until it reaches at least 5.5 cm in diameter, when surgery can then be considered. If it is less than 5.5cm, management includes control of risk factors.

Question 14

Lipodermatosclerosis is a feature of chronic venous insufficiency.

Answer 14

True - Long term venous stasis can lead to sclerosis of tissues of the leg. A leg affected by lipodermatolosclerosis is said to look like an inverted Champaign bottle.

Question 15

A stroke can cause a loss of vision.

Answer 15

True – there are numerous parts of the brain which can cause loss of vision when affected by stroke.

Question 16

The site of a venous ulcer is classically just above the malleoli.

Answer 16

True – as with any “classic” sign, this is not universally the case, but it is very common.

Question 17

A false aneurysm is also known as a pseudo-aneurysm.

Answer 17

True – this occurs when only one layer of the vessel wall is aneurysmal, as occurs in a dissecting aneurysm.

Question 18

The pain experienced with critical lower limb ischaemia is often worse at night and is therefore relieved by elevating the leg.

Answer 18

False - The pain is often worse at night when a patient lies down due to the loss of the effect of gravity which aids the distal supply. Patients often describe hanging their leg off the side of their bed to relieve the pain.

Question 19

Aortic aneurysm screening is offered to all people at age 65.

Answer 19

False. As AAA is 6 times more common in men, females are not screened for this condition as would not fulfil the screening criteria to introduce this service. 2 out of 3 deaths of ruptured AAA are in men aged >65 years.

Question 20

A patient presents with sudden onset of left sided weakness. A stroke is suspected. The left hemisphere of the brain is the side likely to be involved.

Answer 20

False - It is the right side of the brain which controls the motor function on the left side of the body.

Question 21

Care should be taken in administering intravenous contrast to patients who take metformin.

Answer 21

True – particularly in patients with impaired renal function, in whom contrast can precipitate kidney injury. Metformin can cause lactic acidosis in these patients. Generally in patients with impaired renal function, metformin should be withheld for a few doses.

Question 22

Women have a higher risk of heart disease than men.

Answer 22

False. Women are relatively protected until the menopause, and males have a higher risk than females.

Question 23

Ultrasound can not show flow direction or speed.

Answer 23

False. Ultrasound probes can show direction of flow and velocity, and is commonly used to detect DVTs.

Question 24

High blood pressure should NOT be treated in peripheral arterial disease as the high arterial pressure will aid the perfusion of tissues distal to the narrowing.

Answer 24

False - Vascular risk factors should be screened for and managed. SIGN guidelines advise a target BP of below 140/85.

Question 25

The normal diameter of the abdominal aorta is usually 2cm.

Answer 25

True - The Aorta usually has a diameter of around 2cm in normality.

Question 26

Medical Management of peripheral artery disease is similar to coronary artery disease.

Answer 26

True. Risk factors and medical management are broadly similar for both pvd and cad

Question 27

A stroke can be caused by an embolus.

Answer 27

True - A stroke can be caused by an embolus for example from the carotid arteries or left atrium.

Question 28

The dorsalis pedis pulse is felt halfway behind the medial malleolus and Achilles tendon

Answer 28

False. This location is for the posterior tibial pulse. The dorsalis pedis pulse is felt lateral to the extensor hallux tendon.

Question 29

Amputation is the only treatment in critical limb ischaemia.

Answer 29

False - Control of vascular risk factors as well as angioplasty (PTA) or bypass surgery should be considered.

Question 30

An 11 year old patient complains of cold lower limbs. He is found to have hypertension and poor lower limb pulses. A chest x-ray demonstrates rib notching. The likely diagnosis is peripheral vascular disease of the lower limbs.

Answer 30

False - The likely diagnosis is coarctation of the aorta. This may present in infancy with signs of heart failure and failure to thrive. Later in life it may simply present with high blood pressure. Signs may include cold and poorly perfused lower limbs secondary to the coarctation. There may also be radial-femoral delay.

Question 31

A patient was admitted two hours ago after waking up this morning with symptoms of a stroke. They were brought to hospital urgently upon recognising their symptoms. Thrombolysis should be given immediately.

Answer 31

False - Thrombolysis should be given within 4.5 hours of definitive onset of symptoms of a stroke (if no contraindications). We do not know when the stroke symptoms definitely started since they woke up with the symptoms. We also don't know how long it took for the patient to come to hospital. In addition it is important to check for contraindications to thrombolysis, for example we would require a CT scan to exclude a haemorrhagic stroke.

Question 32

Regarding stroke: MCA occlusion can lead to loss of vision in one eye.

Answer 32

False – it can lead to a homonymous hemianopia. This means the same field of vision is lost in both eyes.

Question 33

Varicose veins are commoner in men.

Answer 33

False – varicose veins are commoner in women.

Question 34

In patients presenting with new onset abdominal or back pain an Abdominal Aortic Aneurysm is an important diagnosis to consider.

Answer 34

True - Especially in older patients (Over 55). Ruptured AAA’s are always fatal without appropriate resuscitation and surgery, therefore early recognition and management is important. A diagnosis not to be missed.

Question 35

Catheter angiography involves a sterile procedure, injecting contrast and taking a rapid series of images.

Answer 35

True. This procedure is commonly used for coronary angiogram.

Question 36

Leg ulceration should always be treated with compression therapy.

Answer 36

False - There are many causes of leg ulceration such as venous, arterial or neuropathic ulcers. Compression therapy may be used in venous ulceration to reduce venous stasis and increase venous return. Arterial disease should always be excluded as compression therapy would exacerbate the problem and potentially lead to limb ischaemia.

Question 37

Risk factors for varicose veins do not include DVTs.

Answer 37

False. A DVT disrupts the valve system in veins causing back pressure in the superficial system which results in varicose veins.

Question 38

A patient with claudication symptoms only (without critical ischaemia ) has a lower risk of amputation than critical ischaemia.

Answer 38

True. Intermittent Clarification has a 2% risk over 10 years of amputation. Critical ischaemia has a >30% risk EACH year of amputation

Question 39

A potential complication of a stroke is a Deep Vein Thrombosis.

Answer 39

True - Immobility is a risk factor for the development of a DVT.

Question 40

The pain associated with intermittent claudications is described as sharp.

Answer 40

False - The pain associated with intermittent claudications is described as cramping or a dull ache.

Question 41

Trauma is a risk factor for the development of an aneurysm.

Answer 41

True – trauma can weaken the vessel wall and increase risk of aneurysm or pseudoaneurysm.

Question 42

Dysphasia is slurred speech as a result of a motor deficit.

Answer 42

False - Dysphasia is a disorder of language which can either be expressive or receptive. Expressive dysphasia (Broca’s area) is a disorder of expressive language where an individual knows what they want to say but has difficulty expressing themselves, and speech is laboured and halting. Receptive dysphasia (Wernicke's area) is a disorder where an individual is able to speak fluently, but has difficulty in understanding and using language, and the sentences they speak may be difficult to understand.

Question 43

Smoking is a risk factor in the development of an abdominal aortic aneurysm.

Answer 43

True – like all cardiovascular disease, smoking is a risk factor for AAA.

Question 44

Thrombolysis should be given within 12 hours of definitive onset of symptoms of a stroke (if no contraindications).

Answer 44

False – your timeline is much narrower. SIGN guidelines recommend patients with no contraindications receive thrombolysis within 4.5 hours of symptom onset. “Definitive” means you are sure when symptoms started. For this reason, people who wake up with stroke symptoms are usually not thrombolysed – we don’t know if they had their stroke at the beginning or the end of the night.

Question 45

Marfans syndrome only causes cardiovascular diseases due to aortic dissection and aneurysms.

Answer 45

False. It can causes aortic and pulmonary valve prolapse and regurgitation too

Question 46

Exercise should be advised in patients diagnosed with peripheral arterial disease.

Answer 46

True - Exercise has been shown to improve walking time of patients.

Question 47

Varicose veins can lead to skin changes.

Answer 47

True - Chronic venous insufficiency occurs when there is chronic poor return of venous blood. This can lead to changes in the surrounding leg such as swelling, pigmentation due to haemosiderin deposits, lipodermatosclerosis and venous ulceration

Question 48

Strokes are often caused by emboli from deep vein thrombosis.

Answer 48

False – think about the anatomy involved here. Deep vein thrombosis will embolise through the venous system, ending up in the right side of the heart. Emboli then travel through the pulmonary artery, becoming lodged in the pulmonary vascular bed – causing a pulmonary embolis. Strokes CAN be caused by emboli from deep vein thrombosis, but this is rare, and indicates that there is a hole between the right and left side of the heart. This is called a “paradoxical embolus”.

Question 49

Ultrasound scans have different phases which show up different tissues in the body.

Answer 49

Faslse - CT scans do. Arterial, venous, nephrogenic and delayed phases occur at different time intervals from dye injection: within 15seconds for arterial, and 6-10 mins for delayed phase of CT scan

Question 50

A Doppler test for varicose veins would be as follows – hold Doppler probe over the saphenofemoral junction and squeeze the calf muscles. A double “whoosh” sound is typical sound pattern to show an incompetent saphenofemoral junction.

Answer 50

True. If the valves in the veins were working, a single “whoosh” would be heard. The double “whoosh” is due to blood going in and then coming back down the superficial vein system.

Question 51

In arterial disease of the lower limb, intermittent claudications can only be felt in the calf.

Answer 51

False - Intermittent claudications can be felt in the buttocks, thigh or calf. It depends on the site of the narrowing.

Question 52

The long saphenous vein drains in the groin into the femoral vein (deep system).

Answer 52

True. The short saphenous vein drains into the popliteal vein (deep system)

Question 53

A patient presents with unilateral calf swelling and a raised D-dimer, DVT is suspected. Imaging with compression ultrasound is required to confirm the diagnosis.

Answer 53

True - Diagnosis is based on clinical assessment, D-dimer levels and imaging for example a compression ultrasound scan.

Question 54

Urinary tract calculi are picked up in the delayed phase of a CT scan.

Answer 54

False – calcified structures such as urinary calculi (and bone) will show up on a non-contrast CT scan easily, as they naturally contrast with the surrounding soft tissue. Delayed phase CT is useful for identifying other forms of ureteric obstruction, as the contrast is renally excreted in the urine.

Question 55

Exercise should be encouraged for patients with peripheral vascular disease

Answer 55

True. Walking distance can be increased by 150% if patients walk regularly and this also helps develop a collateral circulation.

Question 56

Chronic venous insufficiency may be caused by a DVT.

Answer 56

True – venous obstruction (by a DVT) can lead to venous insufficiency.

Question 57

Dysarthria is slurred speech as a result of a motor deficit.

Answer 57

True – People with dysarthria have no issue with forming and using language, but the muscles of articulation are weak or paralysed due to stroke.

Question 58

Varicose veins may be secondary to an abdominal mass.

Answer 58

True - An abdominal or pelvic mass can lead to back pressure on the venous drainage of the lower limbs resulting in venous congestion. This can cause varicose veins.

Question 59

Stroke is a sudden onset of neurological deficit which lasts less than 24 hours.

Answer 59

False - This is the definition of a transient ischaemic attack (TIA).

Question 60

Angiography is the investigation of choice to assess varicose veins.

Answer 60

False - Doppler USS scanning is a useful imaging tool as it can assess flow through the veins and can therefore identify valvular incompetence seen in varicose veins.

Question 61

Varicose veins can lead to itching and bleeding.

Answer 61

True - Other symptoms include swelling, pain and skin changes.

Question 62

CT angiography can be use to detect small haemorrhages from vessel leaks in, for example, the GI tract.

Answer 62

False – CT angiography will only reliably identify the source of fairly large, brisk bleeds. Smaller haemorrhages can easily be missed.

Question 63

Carotid Endarterectomy should be considered if there is more than 70% stenosis of the internal carotid artery which is symptomatic.

Answer 63

True – carotid artery disease is a common cause of ischaemic stroke and TIA, and severe stenosis is more likely to be symptomatic.

Question 64

Paraplegia is paralysis of one side of the body.

Answer 64

False - Paraplegia is paralysis of both lower limbs. Hemiplegia is paralysis of one side of the body.

Question 65

Right handed people will usually have centres for language in the left hemisphere.

Answer 65

True - Right handed people will usually have centres for language in the left hemisphere. Left handed will usually have language centres in the right hemisphere. This is not always the case, however.

Question 66

A 50 year old patient with a history of atrial fibrillation presents as an emergency with sudden onset severe pain in his left leg. He has no significant past medical history. Acute limb ischaemia is diagnosed. The likely cause of the occlusion is secondary to an embolus from the heart.

Answer 66

True - With the history of atrial fibrillation and no significant past medical history, an embolus is likely. Remember the 6 P's in acute limb ischaemia - Pain, Paraesthesia, Pallor, Pulseless, Perishing cold, Paralysis.

Question 67

A patient presents with sudden onset of left sided numbness and weakness. A stroke is suspected. The right hemisphere of the brain is the side likely to be involved.

Answer 67

True - It is the right side of the brain which controls the motor function on the left side of the body.

Question 68

Endovascular repair of Abdominal Aortic Aneurysms does not require long term follow up as it is less invasive than open repair.

Answer 68

False - EVAR requires long term follow up due to the risk of endoleak. This procedure involves placing a graft into the aorta over the aneurysm to occlude the dilated sac. This prevents blood from entering the aneurysm sac and causing further dilatation and rupture. The risk is if there is leakage into the sac, despite the occlusive graft, which then has the potential to cause further dilatation and rupture of the aneurysm.

Question 69

A patient presents with sudden onset, left sided arm and leg weakness. There is no sensory involvement and no other deficit detected. A stroke is suspected. This would be classed as a lacunar stroke.

Answer 69

True - Lacunar strokes are small deep infarcts due to occlusion of small penetrating vessels. They can cause deficits including pure sensory, pure motor, sensorimotor or ataxic hemiparesis.

Question 70

An aortic dissection involves a tear in the inner wall of the aorta.

Answer 70

True - A tear in the inner layer causes blood to force the walls of the aorta apart leading to a false lumen.

Question 71

A potential complication of a stroke is pneumonia.

Answer 71

True - Pneumonia is common in stroke patients. One reason is secondary to a poor swallow reflex as a result of the stroke. This can lead to aspiration, resulting in pneumonia.

Question 72

An aneurysm is defined when there is at least a 50% increase in the normal diameter of a blood vessel.

Answer 72

True – In aneurysmal vessels, there is at least a 50% increase in the normal diameter of the vessel.

Question 73

Venous ulcers are commonly found directly over the malleoli and toes in the lower leg.

Answer 73

False. These are the sites for arterial ulcers. Venous ulcers tend to be above the medial and lateral malleoli.

Question 74

An abdominal aortic aneurysm is defined as being 2.5 cm or more.

Answer 74

False - The Aorta usually has a diameter of around 2cm in normality. An abdominal aortic aneurysm can be diagnosed when the diameter is 3cm or more (50% increase from the original diameter).

Question 75

A 65 year old smoker presents to a vascular clinic with intermittent cramping pains in the back of their legs on exertion. The patient is able to walk a mile before they have to stop due to the pain. The first step in the management of this patient is surgical revascularisation.

Answer 75

False - This patient is likely to have a degree of peripheral arterial disease. The patient is able to walk a considerable length before they need to stop due to the pain, so immediate revascularisation is unlikely to be first line. Control of risk factors is essential in all these patients. Smoking cessation should be advised as well as screening and controlling other vascular risk factors such as hypertension, diabetes mellitus and high cholesterol.

Question 76

Atrial fibrillation can cause strokes.

Answer 76

True – fibrillation of the atria leads to stasis of blood in the left atrium and can cause thrombi to form. These can then embolise and travel up the carotid artery, leading to stroke. This is why we anticoagulate patients with AF.

Question 77

A true aneurysm involves weakness and dilatation of a single layer of the vessel wall.

Answer 77

False - A true aneurysm involves weakness and dilatation of all 3 layers of the wall of a vessel.

Question 78

25% of diabetics develop a foot ulcer in their lifetime.

Answer 78

True.That is why foot care in diabetes is important. They should be told to always wear shoes, check the fit of footwear, check pressure points/plantar surface of foot regularly and seek prompt medical help for any skin breaches.

Question 79

95% of abdominal aortic aneurysms are supra-renal.

Answer 79

False - 95% of abdominal aortic aneurysms are infra-renal.

Question 80

An aneurysm always presents with symptoms.

Answer 80

False - It may be asymptomatic. Symptoms may include pain, pulsatile mass, local compression or shock.

Question 81

Most strokes involve a headache.

Answer 81

False – most strokes are painless. Haemorrhagic strokes are more likely to be painful, as blood is highly irritant to the meninges.

Question 82

An aortic dissection could cause aortic regurgitation.

Answer 82

True - Dilatation of the ascending aorta may cause aortic regurgitation.

Question 83

The pain associated with critical limb ischaemia is often felt most distally.

Answer 83

True - Critical limb ischaemia is severe narrowing of the arterial supply to a limb. Pain is at rest and is felt most distally.

Question 84

A 65 year old male presents with a stroke. The commonest thromboembolic cause is from a DVT.

Answer 84

False - The commonest embolic cause of a stroke is from carotid artery disease. It can also arise from the heart, especially in patients with atrial fibrillation. A DVT mainly embolises to the lungs and causes a Pulmonary Embolus.

Question 85

Carotid Endarterectomy should be considered if there is more than 70% stenosis of the internal carotid artery which is symptomatic.

Answer 85

True – carotid artery disease is a common cause of ischaemic stroke and TIA, and severe stenosis is more likely to be symptomatic.

Question 86

A Doppler test for varicose veins would be as follows – hold Doppler probe over the saphenofemoral junction and squeeze the calf muscles. A double “whoosh” sound is typical sound pattern to show an incompetent saphenofemoral junction.

Answer 86

True. If the valves in the veins were working, a single “whoosh” would be heard. The double “whoosh” is due to blood going in and then coming back down the superficial vein system.

Question 87

Lymphoedema may be caused by surgery

Answer 87

True - Dissection of lymph nodes or damage to the lymphatic system during surgery can lead to a loss of lymphatic drainage and result in lymphoedema.

Question 88

A 65 year old smoker presents to a vascular clinic with intermittent cramping pains in the back of their legs on exertion. The patient is able to walk a mile before they have to stop due to the pain. The first step in the management of this patient is surgical revascularisation.

Answer 88

False - This patient is likely to have a degree of peripheral arterial disease. The patient is able to walk a considerable length before they need to stop due to the pain, so immediate revascularisation is unlikely to be first line. Control of risk factors is essential in all these patients. Smoking cessation should be advised as well as screening and controlling other vascular risk factors such as hypertension, diabetes mellitus and high cholesterol.

Question 89

The pain classically associated with aortic regurgitation is severe central crushing chest pain radiating to the left arm.

Answer 89

False - It is classically severe tearing chest pain radiating to the back.

Question 90

Marfans syndrome only causes cardiovascular diseases due to aortic dissection and aneurysms.

Answer 90

False. It can causes aortic and pulmonary valve prolapse and regurgitation too

Question 91

Lipodermatosclerosis is a feature of chronic venous insufficiency.

Answer 91

True - Long term venous stasis can lead to sclerosis of tissues of the leg. A leg affected by lipodermatolosclerosis is said to look like an inverted Champaign bottle.

Question 92

Ankle-Brachial Pressure Index of >0.5 is typical of asymptomatic disease.

Answer 92

False. An ABPI of >1.0 is aysmptomatic disease

Question 93

An aortic dissection can occlude branches of the aorta.

Answer 93

True - The tear in the layers can lead to a false lumen and can occlude blood supply to branches of the aorta such as the carotid, spinal, mesenteric etc.

Question 94

A patient presents with unilateral calf swelling and a raised D-dimer, DVT is suspected. Imaging with compression ultrasound is required to confirm the diagnosis.

Answer 94

True - Diagnosis is based on clinical assessment, D-dimer levels and imaging for example a compression ultrasound scan.

Question 95

Care should be taken in administering intravenous contrast to patients who take metformin.

Answer 95

True – particularly in patients with impaired renal function, in whom contrast can precipitate kidney injury. Metformin can cause lactic acidosis in these patients. Generally in patients with impaired renal function, metformin should be withheld for a few doses.

Question 96

Varicose veins of the lower leg occur in either the long saphenous or the short saphenous veins.

Answer 96

True - These are the two main superficial veins of the lower limb. One or both can be affected.

Question 97

Critical limb ischaemia is defined by a claudication distance of less than 20 metres.

Answer 97

False. Critical limb ischaemia is defined as rest pain, mainly in the feet, and necrosis or gangrene of the limb.

Question 98

With regard to Coarctation of aorta - If coarctation area is after the origin of left subclavian artery then there is radial-radial delay.

Answer 98

False. If coarctation area is before the origin of left subclavian artery then there is radial-radial delay and RIGHT radial–femoral delay.

Question 99

Regarding stroke: MCA occlusion can lead to loss of vision in one eye.