Chapter 4 - Vascular
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. What would you like to do?
An obese patient who smokes presents with pain in his right calf. You are giving only one clinical test you can perform and one imaging test, which would you choose?
I would choose the homan sign which is dorsiflexion the ankle with the knee flexed. A positive sign would be pain with dorsiflexion
I would choose doppler US for imaging.
You can also do pratts sign which is squeezing the calf to see if it elicits pain.
Pt presents with pain in calf when walking about 100 yards. The pain gets so bad he has to wait 5 min before he can resume walking. If you had to guess his ABI what would you say?
I would guess a 0.6
- 0.5 -0.8 = Intermittent claudication
- < 0.5 = rest pain and ulcers
Your attending out of the blue says, "if you can tell me what perthes and trendelenburg's manuever test for you get the program." What is your response?
Perths is used to detect vein valvular incompetence. Use tourniquet around leg to obstruct superficial veins. Pt asked to walk. With valvular incompetence blood will reflux from deep veins through incompetent communicators to superficial venous system. If pt feels pain on walking, this could mean deep venous claudication .
Trendelenburgs Maneuver: Used to differentiate deep and superficial venous incompetence. Elevate leg to empty venous blood. Place tourniquet around upper thigh to occlude superficial venous flow. Have patient stand. If varicosities fill within 20-30 sec. deep and perforation dz is present. If varicosities do no fill after about 30 sec, release tourniquet. If the varicosities promptly return, the sourse of reflux is superficial system.
Will an SVT (superficial venous thrombosis) embolize to the lungs?
No, the connecting vessels from SV to DV are too small.
Pt presents with a painful, cold, numb foot. Podiatric medical physician of foot and ankle surgery diagnoses the patient with a small vessel disease that is caused by proliferation of the intima of small vessels. Since you are a podiatric medical student and future foot and ankle surgeon what is the name of this disease?
Pt has long history of smoking. Pt presents with raynauds phenomenon, intermittent claudication in the arch of foot. No pulses. Physician diagnoses a small medium arterial disease. The physician says this disease is most commonly caused by smoking. What is it? *Hint some people pick these out of their noses and eat them.
As you are visualizing XRAYS with an attending you notice calcific vessels. The attending tells you the pt has good blood flow but decreased pulses. What disease?
Monchebergs dz. This disease is a result of extensive deposits of calcium in media layer of medium size arteries. Usually incidental finding on x-ray. It doesn't decrease blood flow but may decrease pulses due to lack of distensibility.
You have a pt that was just diagnosed with a DVT, the preceptor, who puts alot of trust in you as a student says, "I just got a call from another hospital, I need to leave...please take care of this patient, bye." What do you do?
- Tell the nurse to keep patient bedrest until local tenderness and swelling disappears.
- -Start pt on Heparin of a bolus of 5,000-10,000 units IV followed by a continuous IV infusion of 500 units/kg every 24 hrs.
- -Check PTT 4-6 hrs after initial therapy then at least every 24 hrs. PTT levels should be maintained at 2-3 times the control value.
- -Pt should later be started on long term anticoags loading dose of 10mg each day until PT increases. Then a smaller dose is given to maintain PT around 1.3-1.5 above the control value. Pts should be Tx for 3 months for the 1st episode.
How do you differentiate between venous insufficiency and lymphedema?
- Nonpitting edema is a sign of lymphatic obstruction
- Pitting edema is a sign of chronic venous obstruction
Lymphangitic streaks may be seen in the skin, and lymph nodes in the groin are usually enlarged and tender.
The onset for lymphedema is explosive, with chills, high fever, toxicity, and a red hot swollen leg. (may be a result from infection or obliteration of lymphatic tissue by excision or radiation therapy.)
Lymphedema doesnt respond well to elevation and varicosities are absent.
What is needed to heal digital wound?
What would you like to do?
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