HY lecture notes:
Medial malleolus ulcer + hyperpigmentation of lower legs; Dx? –> chronic venous insufficiency.
Punched-out ulcer on foot + intermittent claudication; Dx? –> arterial insufficiency (peripheral vascular disease).
What causes venous insufficiency? –> valvular incompetence (most commonly familial), resulting in venous reflux + insufficiency.
What causes arterial insufficiency –> atherosclerosis (diabetes, followed by smoking, are the two most acceleratory risk factors; hypertension is the most common risk factor).
How do you Dx venous insufficiency? –> duplex ultrasound of the calves showing stasis and/or occlusive disease (the latter may result from venous insufficiency or cause it).
How do you Dx arterial insufficiency? –> USMLE always wants ankle-brachial indices (ABI) first –> after this is done, the answer is Doppler ultrasound of the calves (duplex ultrasound is the answer for venous) or arteriography; both of these latter answers are correct; they will not give you both; it will be one or the other.
Tx for venous insufficiency –> compression stockings.
Tx for varicose veins –> compression stockings.
Varicose veins and venous insufficiency same thing? –> varicose veins are one of the mere presentations of venous insufficiency, so yes, patients with varicose veins have venous insufficiency.
47F has varicose veins + painful palpable cord by the ankle (is the treatment compression stockings or subcutaneous enoxaparin; both are listed) –> answer = subcutaneous enoxaparin because this is superficial thrombophlebitis.
Tx for arterial insufficiency –> exercise regimen first, THEN cilostazol (phosphodiesterase 3 inhibitor).
What must you do before starting the exercise regimen in the Tx of arterial insufficiency –> ECG stress test to ascertain patient’s exercise tolerance.
What is patient has abnormal baseline ECG (e.g., BBB) –> do echo stress test instead.
What if the patient can’t exercise –> do dobutamine-echo stress test.
82M + Hx of atrial fibrillation + acutely painful lower limb; Dx + Tx? –> acute limb ischemia due to embolus to lower limb; Dx is clinical (presentation), but arterial Doppler ultrasond an be performed; Tx = heparin + oxygen + morphine. Embolectomy / percutaneous intervention may be performed.
82M + Hx of intermittent claudication + acutely painful lower limb; Dx? –> also acute limb ischemia –> rather than an embolus, caused by thrombosis from ruptured atherosclerotic plaque. Tx as per above.
