DVTs

Question 1

What is a DVT?

Answer 1

Blood clot in the deep veins

Question 2

What is the most common area for DVTs to occur?

Answer 2

Legs
10x more common than upper extremity
Usually starts in calf & spreads proximally

Question 3

Do distal DVTs have more or less risk of clot embolizing to lungs?

Answer 3

Less risk

Question 4

Do proximal DVTs (popliteal or femoral veins) have high or low incidence of pulmonary embolism?

Answer 4

Higher

Question 5

Are varicose veins a significant risk for DVT?

Answer 5

No

Question 6

Does venous stasis promote or decrease thrombus formation?

Answer 6

Promote

Question 7

What makes up Virchow’s triad?

Answer 7

Venous stasis
Hypercoagulability
Inflammation

Question 8

Does thrombosis happen before or after an event of Virchow’s triad has occurred?

Answer 8

After

Question 9

What increases the risk of DVT? (7)

Answer 9

Family history of DVT
Immobilization
Recent major surgery/trauma
Active cancer/ chemotherapy
Age over 60
Systemic diseases
Pregnancy, estrogen

Question 10

Are individual DVT risk findings reliable?

Answer 10

No- you will need to use clinical prediction guidelines to predict likelihood of DVT

Question 11

What are some findings when a patient has a DVT?

Answer 11

asymmetric calf swelling
(also includes Baker’s cyst in or near popliteus)
asymmetric warmth & redness
acute cellulitis which signifies subcutaneous CT infection
exquisitely tender to touch
asymmetric edema (most likely acute onset)

Question 12

If a patient has chronic edema & skin changes that include thickening and a dusky color, what is a possible diagnosis?

Answer 12

Chronic Venous Insufficiency

Question 13

What is chronic venous insufficiency caused by?

Answer 13

incompetent valves in the deep veins

can also be a DVT complication

Question 14

What could be a helpful treatment for chronic venous insufficiency?

Answer 14

venous compresion

Question 15

Is chronic venous insufficiency unilateral or bilateral usually?

Answer 15

Can be either

Question 16

What are some typical findings of chronic venous insufficiency?

Answer 16

medial lower leg skin changes above the ankle
there may or may not be an ulcer
calf muscle cords/ tenderness
Homan’s sign (no longer considered reliable)
medial calf size greater than 3cm larger than other leg (could be from swelling for something other than a DVT as well)

Question 17

What is used to predict DVT probability?

Answer 17

Clinical prediction guide such as Wells DVT Clinical Prediction Rules

Question 18

If a patient has bilateral lower extremity pitting edema do they get a point on Wells DVT Clinical Rules?

Answer 18

NO- because it should be unilateral, not bilateral

Question 19

How long would a patient have restricted mobility (such as bedridden for more than 3 days or major surgery) in order to give them a point on Wells DVT Clinical Rules?

Answer 19

4 weeks

Question 20

How recent would an active malignancy have to be in order to give a patient a point on Wells DVT Clinical Rules?

Answer 20

Within the last 6 months

Question 21

If the circumference of one calf over the other is 2cm how many points does the patient receive on Wells DVT Clinical Rules?

Answer 21

0 points- because it has to be greater than 3cm difference

- measure this 10cm below tibial tuberosity

Question 22

How many points does a patient receive on Wells DVT Clinical Rules if they have varicose veins?

Answer 22

0 points

- 1 point is given for NON-varicose collateral superficial veins

Question 23

On Wells DVT Clinical Rules what do you deduct 2 points for?

Answer 23

strong alternative to DVT, if there is another diagnosis that is at least as likely as DVT

Question 24

On Wells DVT Clinical Rules, your patient gets 0 points, what this indicate?

Answer 24

Low probability (3% DVT frequency)

Question 25

On Wells DVT Clinical Rules, your patient gets 1-2 points, what this indicate?

Answer 25

Medium probability (17% DVT frequency)

Question 26

On Wells DVT Clinical Rules, your patient gets >2 points, what this indicate?

Answer 26

High probability (75% DVT frequency)

Question 27

What do you do if you suspect a DVT?

Answer 27

Get an urgent ultrasound done

Question 28

What do you use a D-dimer blood test for? How do you interpret it?

Answer 28

To test for DVT Negative= NO DVT Positive does NOT rule IN a DVT (imaging is required for this)

Question 29

What is a potentially fatal complication of DVT?

Answer 29

Pulmonary Embolus

Question 30

What is the classic triad of a pulmonary embolus?

Answer 30

Hemoptysis Dyspnea Chest pain (all 3 occur in less than 20% of cases)

Question 31

What is the treatment for a suspected DVT?

Answer 31

Go to the ER! for anticoagulation medication to prevent further clotting May require meds to dissolve the clot as well

Question 32

What are 5 red flags for a cardiac problem?

Answer 32

``` Chest Pain!! Palpitations Pre-syncope/syncope SOB/DOE LE Swelling (edema) ```

Question 33

What are the 2 categories of chest pain?

Answer 33

Visceral (vague) | Pleuritic

Question 34

Explain how the patient might present if they are having cardiac visceral pain.

Answer 34

Hard for patient to localize/ describe | Not made worse by palpation, changes in body position, or taking deep breaths

Question 35

What is a typical example of cardiac visceral pain?

Answer 35

Angina (cardiac ischema)

Question 36

When do you see cardiac pleuritic pain?

Answer 36

When the pericardium is inflamed and irritates the parietal pleura= pericarditis

Question 37

Why is parietal pleura so pain sensitive?

Answer 37

Because parietal pleura lines the chest wall in close proximity to the intercostal nerves

Question 38

Explain how a patient might present if they are having cardiac pleuritic pain.

Answer 38

Easier to localize/describe (usually retrosternal or left chest & sharp pain) Not made worse by palpation but WORSE with breathing and lying supine

Question 39

What might make pericarditis pain feel better?

Answer 39

Sitting & leaning forward

Question 40

When is pleuritic chest pain most often seen?

Answer 40

Lung conditions & pericarditis & 14% of MIs

Question 41

Differential Diagnosis for chest pain can also include what other conditions?

Answer 41

GI problems Anxiety Musculoskeletal conditions

Question 42

Is pre-syncope/syncope specific to heart disease?

Answer 42

No

Question 43

What leads to pre-syncope/syncope?

Answer 43

Global reduction of cerebral perfusion

Question 44

What do benign forms of pre-syncope/syncope tend to have?

Answer 44

Prodrome

Question 45

How long is the prodrome for vasovagal syncope?

Answer 45

about 2.5 minutes

Question 46

If your patient has short (3-5secs) or no prodrome what can this indicate?

Answer 46

Cardiogenic syncope (usually this is not benign and must be investigated further)

Question 47

Are palpitations alone specific to heart disease?

Answer 47

No

Question 48

What does a combo of palpitations and pre-syndope/syncope indicate?

Answer 48

Arrhythmia | must investigate further

Question 49

What is a potential indicator for cardiovascular disease?

Answer 49

Peripheral arterial disease

Question 50

What is a modifiable cardiovascular risk factor?

Answer 50

Stacking (finger stacking)

Question 51

What are the non-modifiable risk factors for CVD?

Answer 51

Patient age Male = 45, Female = 55 results in CVD risk increase Family history of premature heart disease in a first degree relative (premature male= 55, female = 65)

Question 52

What does Nitric Oxide promote?

Answer 52

Vasodilation (and can limit platelet clotting)

Question 53

What are some pathophysiological factors that can contribute to CVD?

Answer 53

``` arterial "stiffness" injured endothelium (due to decreased NO) increased risk of vasoconstriction & clotting ```

Question 54

CV risk factors can lead to activation of endothelium. What does this refer to and what does it cause the formation of?

Answer 54

Activation of endothelium refers to leukocyte recruitment & this leads to the formation of Foam Cells

Question 55

In CVD, what happens after foam cells are formed?

Answer 55

An inflammatory cascade is triggered in artery wall which causes plaque formation.

Question 56

What area of an artery is most prone to atherosclerosis?

Answer 56

Arterial bifurcations

Question 57

What is the strongest modifiable risk of CVD?

Answer 57

Diabetes mellitus | some risk present even when glucose levels are under control

Question 58

What is the second strongest modifiable risk of CVD?

Answer 58

Smoking (proportional to number of smoked and depth of inhalation) Second hand smoke also counts

Question 59

Outside of diabetes and smoking, what are other modifiable risks of CVD?

Answer 59

``` Sedentary lifestyle Body weight/ obesity Hypertension High LDL levels Hypertriglyceridemia Low HDL ```

Question 60

What causes most heart attacks?

Answer 60

Plaque rupture & subsequent clot formation

Question 61

Do all heart attacks occur in patients with high LDL levels?

Answer 61

No

Question 62

Explain how MI often happens due to high LDL.

Answer 62

Oxidation of LDLs causes inflammatory cascade, and this inflammation may lead to plaque rupture= CV event

Question 63

Explain the cholesterol treatment controversy

Answer 63

- statin meds for those with normal LDL levels to stabilize plaques EIP suggests this is what leads to decreased CV deaths

Question 64

What can lead to hypertriglyceridemia?

Answer 64

Obesity Uncontrolled diabetes Chronic alcoholism