Week 04.Cardiovascular

Question 1

Causes of bilateral leg edema

Answer 1

pulmonary HTN
hypoalbuminemia
NSAIDs

Question 2

name a cause of decreased oncotic pressure

Answer 2

hypoalbuminemia

Question 3

name some causes of increased hydrostatic pressure

Answer 3

fluid retention (HF, NSAIDs, corticosteroids)
venous incompetence
DVT
pulmonary HTN
venodilating drugs (Calcium channel blockers)

Question 4

name 3 major causes of unilateral leg edema

Answer 4

DVT
cellulitis
popliteal Baker’s cyst

Question 5

name some causes of acquired hypercoagulability

Answer 5

cancer
illnesses associated with production of antiphospholipid antibodies
prolonged immobilization
recent major surgery

Question 6

most common hereditary factor associated w/ hypercoagulability

Answer 6

Factor V Leiden mutation

Question 7

factors that increase the risk of DVT

Answer 7

estrogen and progestin
obesity
Factor V Leiden mutation
increasing age
pregnancy
postpartum (risk greatest in initial 6 weeks after delivery; risk continues up to 12 weeks postpartum)
prior DVT

Question 8

textbook signs of DVT

Answer 8

unilateral leeg edema
calf tenderness
palpable cord
positive Homans sign

Question 9

where do most DVT occur in pregnancy?

Answer 9

veins of left leg or iliac vein

Question 10

signs that most indicate DVT

Answer 10

asymmetric leg edema
swelling of entire leg
pitting edema of involved leg
tenderness along deep veins
prominent collateral superficial veins

Question 11

name some signs of iliac DVT

Answer 11

swelling of entire leg
unilateral back pain
swelling of flank and buttock

Question 12

name the familial condition that causes excess fat deposition in the bilateral lower extremities

Answer 12

lipedema

Question 13

What bloodwork can be combined with the Wells score to determine if a patient needs further testing to rule out DVT?

Answer 13

D-Dimer

Question 14

What is the D-Dimer?

Answer 14

final degradation product of thrombosis-induced fibrinolysis

Question 15

How to adjust D-Dimer for age (since D-Dimer increases with age)?

Answer 15

10x age in years

Question 16

In a patient with intermediate risk for DVT, what needs to be done if the duplex is negative?

Answer 16

possibly repeat duplex in a week

First, draw a D-dimer; if D-dimer is negative, duplex can be omitted; if D-dimer is positive, repeat the duplex in a week

Question 17

When should the clinician test a patient with DVT for hypercoagulability? Why?

Answer 17

when family history suggests a risk of DVT and there are no other obvious risk factors to account for DVT; results influence decisions regarding anticoagulation

Question 18

name some organs possibly at fault for bilateral leg edema

Answer 18

heart (heart failure)
lungs (pulmonary hypertension)
kidneys (renal failure, hypoalbuminemia)
liver (hypoalbuminemia)

Question 19

if a patient presents with bilateral DVT, what testing needs to be done?

Answer 19

bilateral doppler ultrasound of lower extremities

Question 20

If a patient has bilateral DVTs, what must be investigated?

Answer 20

possibility of malignancy

Question 21

Name some patient education points for edema due to increased hydrostatic pressure or decreased oncotic pressure

Answer 21

reduced salt intake
elevate legs
avoid prolonged standing
avoid prolonged sitting with legs dependent
support stockings
avoid wearing restrictive clothing

Question 22

important education for patients with chronic leg edema

Answer 22

call physician at first sign of unilateral increase in swelling or pain d/t increases risk of DVT

Question 23

What simple screening needs to be done if a patient presents with bilateral DVTs (or also, recurrent DVTs, or upper extremity DVTs)?

Answer 23

careful history
physical examination
CBC
chemistries
CXR

Question 24

In addition to 
careful history
physical examination
CBC
chemistries
CXR

what additional screening should be done to rule out cancers in a patient presenting with bilateral DVTs?

Answer 24

tumor markers

abdominal ultrasound and/or abdominopelvic CT scanning

Question 25

``` In screening for cancer in a patient who presents with bilateral DVTs, the following should be done: careful history physical examination CBC chemistries CXR ``` This only identifies about 50% of the causative cancers. Why are these the tests that are done?

Answer 25

This focuses on cancers that are treatable.

Question 26

A patient presents with an upper extremity DVT. What is the concern?

Answer 26

increased risk of thromboembolization and PEs | possible cause = malignancy

Question 27

What are some possible causes of upper extremity DVT?

Answer 27

central and other long-line venous catheters pacemaker placement malignancy

Question 28

For what is the Constans clinical decision score used?

Answer 28

to risk stratify patients with suspected upper extremity DVT

Question 29

explain the protocol for testing in suspected upper extremity DVT

Answer 29

Compute Constans score and do D-dimer testing If Constans score 1 (unlikely) and D-dimer rules out coagulability, no need for ultrasound If Constans score 2 or 3, considered likely to have DVT; do ultrasound. If ultrasound positive, anticoagulate. If ultrasound negative, do D-dimer testing; if D-dimer testing negative, DVT ruled out; if D-dimer positive, retest by ultrasound. (Note: ultrasound refers to compression ultrasound; failure rate in detecting DVT by this protocol is 0.4%)