Passmedicine Flashcards
(112 cards)
1
Q
What is the ankle branchial pressure index?
A
Ratio of systolic BP in lower leg to that in the arms
2
Q
What is an ABPI <1 indicative of?
A
Lower BP in legs than arms
Indicative of peripheral arterial disease
3
Q
In which patients might you do an ABPI?
A
Those with leg ulcers
Those with suspected PAD - e.g. smoker with intermittent claudication
4
Q
Why is it essential to measure APBI in those with leg ulcers?
A
Venous ulcers are treated with compression bandaging + doing this in a patient with PAD could further restrict blood flow to the foot
5
Q
ABPI >1.2 = ?
A
Calcified, stiff arteries (may be seen in advanced age, diabetics)
6
Q
ABPI = 1-1.2 =?
A
Normal
7
Q
ABPI = 0.9-1 =?
A
Acceptable
8
Q
ABPI <0.9 =?
A
PAD
9
Q
ABPI <0.5 =?
A
Severe PAD - treat urgently
10
Q
What value of ABPI is considered generally acceptable for use of compression bandaging?
A
0.8 or above
11
Q
What causes abdominal aortic aneurysm?
A
Failure of the elastic proteins within the ECM
Most aneurysms caused by degenerative disease
12
Q
What layers of the aorta are typically dilated in an AAA?
A
Usually all of the layers
13
Q
What is the normal diameter of the aorta in those >50?
A
F - 1.5cm
M - 1.7cm
14
Q
What diameter of infrarenal aorta is considered aneurysmal?
A
3cm+
15
Q
What is the pathophysiology of AAA?
A
Primary event is loss of intima with loss of elastic fibres from the media
Process assoc. w increase in proteolytic activity + lymphocytic infiltration
16
Q
What are RFs for AAA?
A
Smoking
HTN
Syphilis
Connective tissue dx (EDS, Marfans)
17
Q
What is the screening for AAA?
A
All men 65y are offered screening with a single abdominal USS
18
Q
At what ABPI do intermittent claudication symptoms start?
A
0.9-0.8
19
Q
At what ABPI do those with PAD get rest pain but still have intact pedal pulses and no skin changes?
A
<0.5
20
Q
At what ABPI do those with PAD get gangrene + ulcers?
A
<0.3
21
Q
What action is required if an aorta diameter is <3cm on screening?
A
No further action
This is normal
22
Q
What action is required if an aorta diameter is 3-4.4cm on screening?
A
Small aneurysm - rescan every 12m + optimise RFs (e.g. stop smoking)
23
Q
What action is required if an aorta diameter is 4.5-5.4cm on screening?
A
Median aneurysm
Rescan every 3m + optimise RFs (e.g. stop smoking)
24
Q
What action is required if an aorta diameter is >=5.5cm on screening?
A
Refer within 2 weeks to vascular surgery for probable intervention
25
What aneurysms are at high risk of rupturing?
Symptomatic
| Aortic diameter =>5.5cm or rapidly enlarging (>1cm/year)
26
How should high risk aneurysms be managed?
Refer within 2 weeks to vascular surgery
| Treat with elective endovascular repair/open repair if unsuitable
27
What happens in EVAR?
Stent placed into abdominal aorta via femoral artery to prevent blood collecting in the aneurysm
28
What is a common complication of EVAR?
Endo-leak (stent fails to exclude blood from aneurysm)
29
What are the only two situations that require urgent AAA surgery as opposed to elective?
Symptomatic aneurysm or emergency rupture
30
What is PAD strongly linked to?
Smoking
31
How is PAD managed?
```
Quit smoking
Treat co-morbs (HTN, DM, obesity)
80mg atorvastatin
Clopidogrel 75mg
Exercise training
```
32
How is severe PAD managed?
Angioplasty
Stenting
Bypass surgery
33
When might amputation be used in PAD?
Those with critical limb ischaemia who are not suitable for other interventions
34
What drugs are licensed for PAD?
Naftidrofuryl oxalate
| Cilostazol
35
What is naftidrofuryl oxalate?
Vasodilator
36
What is cilostazol?
Phosphodiesterase III inhibitor - has antiplatelet and vasodilator effects
37
What are the three main patterns of presentation seen in those with PAD?
Intermittent claudication
Critical limb ischaemia
Acute limb threatening ischaemia
38
Define critical limb ischaemia
1+ of:
Rest pain in foot for >2w not helped by analgesia
Ulceration
Gangrene
39
What do patients with critical limb ischaemia often describe helping their pain?
Hanging their leg out of bed at night to ease the pain
40
What ABPI is suggestive of critical limb ischaemia?
<0.5
41
What are the symptoms of acute limb ischaemia?
```
6Ps -
Pale
Pulseless
Paraesthesia
Pain
Paralysis
Perishingly cold
```
42
What are the features of intermittent claudication?
Intermittent aching/burning in legs following walking
Can typically walk a predictable distance before symptoms start
Usually relieved within minutes of stopping
Not present at rest
43
How do you assess someone presenting with intermittent claudication?
Check femoral, popliteal, posterior tibialis and dorsalis pedis pulses
ABPI
Duplex USS is first line
MRA should be performed prior to any intervention
44
Stenosis of the femoral vessels leads to symptoms where?
Calves
45
Stenosis of the iliac vessels leads to symptoms where?
Buttocks
46
What symptoms do you get with aortic dissection?
Chest pain
47
What does the position of the chest pain tell you about the location of an aortic dissection?
Ant chest pain --> ascending aorta
Back pain --> descending aorta
48
What do you see on X-ray in an aortic dissection?
Widening of the aorta
49
What imaging is used to diagnose an aortic dissection?
CT
50
What is the treatment of aortic dissection?
Medical - type B
| Surgery - type A
51
What is a cervical rib?
Supernumery fibrous band arising from C7 vertebra
52
What can a cervical rib cause?
Thoracic outlet syndrome
53
What is involved in the treatment of a cervical rib?
Surgical division of rib
54
What is subclavian syndrome
Proximal stenotic lesion of subclavian artery --> retrograde flow through vertebral or internal thoracic arteries --> decrease in cerebral blood flow --> syncopal symptoms
55
What imaging is useful for subclavian steal syndrome?
Duplex +/or angiogram allows you to delinate lesion
56
What is Takayasu's arteritis?
Large vessel granulomatous vasculitis that leads to intimal narrowing
57
Who tends to get Takayasu's arteritis?
Young Asian females
58
How does Takayasu's arteritis present?
Features of mild systemic illness, followed by a pulseless phase with symptoms of vascular insufficiency
59
How is Takayasu's arteritis treated?
Systemic steroids
60
What is patent ductus arteriosus?
Ductus arteriosus is a normal foetal vessel that should close spontaneously after birth but doesn't
61
What does PDA lead to?
High pressure, oxygenated blood entering the pulmonary circuit, can lead to symptoms of congestive cardiac failure
62
What condition is coarctation of the aorta associated with?
Turner's syndrome
63
What are symptoms of coarctation of the aorta?
```
Symptoms of arterial insufficiency, e.g. syncope/claudication
BP mismatch (e.g. in lower vs upper limbs)
```
64
How do you treat coarctation of the aorta?
Angioplasty/surgical resection
65
What types of things may affect upper limb circulation?
Embolic events
Inflammatory disorders
Venous diseases
Stenotic lesions (internal + external)
66
If the subclavian/axillary arteries are occluded why might you not get symptoms all the time?
Collateral vessels around shoulder joint may provide alternative pathways for flow
If inc. metabolic demand collateral flow will be insufficient + vertebral arteries will have diminished flow --> syncope etc.
67
Where is the most common place for an upper limb emboli to lodge?
Brachial artery
68
Whereis the second most common place for an upper limb embolus to lodge?
Axillary artery
69
What are the features of an axillary/brachial embolus?
Sudden onset: pain, pallor, paresis, pulselessness, paraesthesia
70
What are the sources of emboli in axillary/brachial embolus?
Cardiac arrhythmia (e.g. AF), mural thrombus
71
What tends to cause most arterial occlusions?
Atheroma
72
What are features arterial occlusion in the upper limb?
Claudication, ulceration, gangrene
Proximal lesions may --> subclavian steal syndrome
73
Why do you not get acute ischaemia in atheroma arterial occlusions?
Progressive nature of disease allows for development of collaterals
74
Who does Raynaud's tend to affect?
Young females
75
What part of the body does Raynaud's tend to affect most?
Hands
| sometimes feet
76
What colour do your fingers go in Raynaud's?
White --> blue --> red
77
How do you treat Raynaud's?
Calcium antagonists
78
How does upper limb venous thrombosis present?
Gradual onset upper limb swelling + discomfort
| Sensation + motor function normal
79
What may cause upper limb venous thrombosis?
Pre-existing malignancy (esp. breast cancer)
| Due to repetitive use of limb, e.g. painting a ceiling
80
How is upper limb venous thrombosis diagnosed?
Duplex USS
81
How is upper limb venous thrombosis treated?
Anticoagulation
82
What % of cervical ribs are bilateral?
70%
83
What signs may you see in cervical ribs?
Compression of subclavian artery may --> absent raidla pulse
+ve Adsons test
84
What is Adson's test?
Lateral flexion of neck away from symptomatic side + traction of symptomatic arm leads to obliteration of radial pulse
85
When might you get surgery for a cervical rib?
If evidence of neurovascular compromise
86
How is acute limb ischaemia managed?
Surgical intervention to save the leg (symptoms <6h ago high probability of success of surgery)
87
What causes most venous leg ulcers?
Venous hypertension (due to chronic venous insufficiency)
88
What are other causes of venous hypertension other than chronic venous insufficiency?
Calf pump dysfunction
| Neuromuscular disorders
89
What causes ulcers to form in venous hypertension?
Capillary fibrin cuff or leucocyte sequestration
90
What are the features of chronic venous insufficiency?
Oedema
Brown pigmentation (haemosiderin deposition)
Lipodermatosclerosis (champagne bottle legs)
Eczema
91
Where do venous ulcers tend to be?
Above the medial malleolus
92
Are venous ulcers painful?
No
93
What is deep venous insufficiency related to?
Previous DVT
94
What is superficial venous insufficiency associated with?
Varicose veins
95
How do you diagnose venous insufficiency?
Look for reflux
| Duplex USS looks at anatomy/flow of vein
96
How do you manage venous ulcers?
4 layer compression banding after excluding arterial dx
97
If a venous ulcer fails to heal after 12w or is >10cm2 what treatment might be considered?
Skin grafting
98
What is a Marjolin's ulcer?
Squamous cell carcinoma
99
Where do Marjolin's ulcers occur?
On sites of chronic inflammation, e.g. burns/OM after 10-20y
100
Where do you tend to find arterial ulcers?
Toes/heel
101
Are arterial ulcers painful?
Yes
102
What may you see in arterial ulcers?
Areas of gangrene
103
What other signs may you find in the leg of someone with an arterial ulcer?
Cold leg
No palpable pulses
Low ABPI
104
Where do you commonly find neuropathic ulcers?
Plantar surface of metatarsal head and plantar surface of hallux
105
What causes neuropathic ulcers?
Pressure
106
How are neuropathic ulcers managed?
Cushioned shoes to reduce callous formation
107
What two conditions is pyoderma gangrenosum associated with?
Inflammatory bowel disease
| RA
108
What is the appearance of pyoderma gangrenosum?
Erythematous nodules/pustules which ulcerate (looks like margherita pizza with red base and yellow toping)
109
Where might pyoderma gangrenosum occur?
At stoma sites
110
How is pyoderma gangrenosum treated?
Steroids
111
What can an ABPI >1 indicate?
Vessel calcification (common in diabetics)
112
What is the biggest risk factor for thrombo-embolic acute limb ischaemia?
AF
