T1W3

Question 1

branches of common iliac artery and their next branches

Answer 1

common iliac artery –> internal and external iliac
external –> femoral and lower limb supply
internal –> gluteal arteries

Question 2

branches of external iliac artery

Answer 2

external iliac artery –> common femoral artery (after passing inguinal ligament) –> superficial and deep femoral artery

Question 3

branches of superficial femoral artery

Answer 3

superficial femoral artery –> popliteal artery –> genicular branches (supplying the knee)
popliteal artery –> anterior and posterior tibial arteries

Question 4

branches of anterior tibial artery

Answer 4

dorsalis pedis artery

Question 5

branches of posterior tibial artery

Answer 5

fibular artery

Question 6

what is primary hemostasis

Answer 6

endothelial damage –> underlying collagen exposure –> binding of platelets via specific glycoprotein receptors (this adhesion is accelerated by vWF) –> platelet adherence and activation –> degranulation (5HT, vWF, PAF, TXA2 –> further platelet adhesion and activation –> +ve feedback loop –> platelet plug formation

Question 7

components of secondary hemostasis (coagulation cascade)

Answer 7

intrinsic pathway (XII)
extrinsic pathway (TF, VII)
common pathway (Xa, thrombin, fibrin)

Question 8

what are the anticoagulant systems

Answer 8

1. protein C –> aPC –> activated protein S –> prothrombinase complex (Xa) inhibition
2. antithrombin system - inhibit thrombin (II–> IIa) AND also Xa
3. plasminogen/plamin - lyses clot to FDPs

Question 9

components of Well’s PE score

Answer 9

Don’t, Die, Tell, The Team, To, Calculate, Criteria
DVT/PE symptoms/signs present
DVT/PE is #1 diagnosis or equally likely
3 days immobilisation or thirty days surgery
Thromboembolism in the past
Coughing up blood - hemoptysis
Cancer - ongoing malignancy and treatment

Question 10

well’s scoring for PE

Answer 10

two tier model
PE unlikely: 0-4 points - consider D Dimer testing/PERC score
PE likely: >4 points - consider CTA testing

Question 11

causes of raised D dimer

Answer 11

physiological: pregnancy, older age, smoking, post operative, race (blacks)
pathological: ACS, acute upper GI hemorrhage, aortic dissection, malignancy, infection, AF or tachyarrhythmias, consumptive coagulopathy

Question 12

causes of arterial ulcers

Answer 12

PVD - atherosclerosis, T2DM, smoking

vasculitis - rheumatoid arthritis, SLE, polyarteritis nodosa

Question 13

causes of venous ulcers

Answer 13

DVT, varicose veins

chronic venous insufficiency

Question 14

causes of neuropathic ulcers

Answer 14

T2DM, renal failure, trauma, surgery

Question 15

causes of malignant ulcers

Answer 15

BCC, SCC, melanoma

Question 16

when is bacteriological swabbing indicated

Answer 16

only if evidence of clinical infection - inflammation, redness, cellulitis, hyperalgesia, purulent exudate, rapid progression, pyrexia, foul odour - i.e. looks infected

Question 17

why still swab chronic ulcers?

Answer 17

no evidence, however need to determine if any resistant organisms - Abx planning

Question 18

features of a venous ulcer

Answer 18

painful, wet, oozing
bleeds on touch - moist granulating base
large, irregular, shallow
gaiter region and surrounding stasis dermatitis/hemosiderin staining

Question 19

features of an arterial ulcer

Answer 19

painful, dry, irregular clear border
does not bleed on touch - dry granulating base
surrounding gangrenous tissue (black/grey)
associated with CLI - cold, pale feet and weak or absent pulses
shiny atrophic skin with hair loss
distal sites

Question 20

features of neuropathic ulcers

Answer 20

punched out, deep and caving, painless
occurs on pressure points in distal areas
surrounded by calluses (hyperkeratosis)
bleeds
associated with pulselesness and poor peripheral sensation

Question 21

groups who get neuropathic ulcers

Answer 21

diabetics, spinal cord injuries, B12 neuropathy

Question 22

warfarin reversal

Answer 22

vitamin K stat 10mL IV - takes 24hrs to achieve effect

give prothrombin complex concentrate and FFP

Question 23

modifiable risk factors for PVD

Answer 23

Same as CV risk factors:

hyperlipidemia, HTN, high TAG, smoking, T2DM, sedentary lifestyle and physical inactivity

Question 24

non modifiable risk factors for PVD

Answer 24

FMH, male gender, age, genetics - race (more common in blacks)

Question 25

risk factors for skin cancer

Answer 25

``` UV radiation skin type PMH skin cancer FMH skin cancer large number of moles history of severe sun burn ```

Question 26

advice to patients re. warfarin

Answer 26

adherence to medication regular monitoring tell Dr if sick or unwell especially with diarrhoea, vomiting, infection or fever normal diet - vitamin K stable in diet, avoid vitamin K rich foods

Question 27

contraindications to warfarin

Answer 27

alcoholic - high risk injury and bleeding poor compliance protein C or S deficiency already increased risk of severe bleeding - severe HTN, hepatic disease, thrombocytopenia pregnancy several drug interactions - monitoring

Question 28

components of CHA2DS2-VASc score

Answer 28

components CHF (recent signs/sx/admission, or reduced systolic LV function - regardless if hx heart failure) HTN - on treatment or over 140/90mmHg A2 - age 75 or above Diabetes S2 - history of stroke or TIA or systemic thromboembolism Vascular disease (prior MI, PVD or aortic atheroma on imaging) A - age 65-74yrs Sex (female)

Question 29

why use CHA2DS2 VASc score

Answer 29

risk of stroke for patients with non rheumatic AF

Question 30

scoring of CHA2DS2 VASc score

Answer 30

0 - low risk - no anticoagulation 1 - low-intermediate risk - consider anticoagulation (2.8%) 2 - moderate - high risk - anticoagulate (4%)

Question 31

HASBLED score use

Answer 31

estimates 1 year risk of major bleeding for patients on anticoagulation to assess risk-benefit in AF care

Question 32

HASBLED components

Answer 32

Hypertension - uncontrolled SBP>160mmHg Abnormal renal and liver function Stroke - prior history of stroke Bleeding - prior major bleeding or predisposition to bleeding Labile INR - unstable/high INR - time in range >60% Elderly - age >65yrs Drugs or alcohol - prior use >8STDs/week, medication use (NSAIDs, antiplatelets) 1 point each

Question 33

HASBLED scoring

Answer 33

1 - low risk - relatively low risk (3.4%) 2 - moderate risk - but not at high risk of major bleeding (4.1%) 3 - high risk - alternatives to anticoagulation should be considered (4x higher risk for major bleeding)