PAD, AAA

Wu Chean3/3/14

Q1: You are the FY1 in A&E

Referral from GP:Thank you for seeing this 65 y.o. male with a painful foot and worsening gangrenous left 3rd toe which started 4 weeks ago after an initial mild trauma.

After further history taking and examination, you decided that this was a critical ischaemic leg with a wet gangrene.

1a. Apart from smoking and hypertension, name 4 risk factors for PAD.• Diabetes• Male• Hypercholesterolaemia• Family history• Obesity• Old age

1b. What is the expected value of ABPI in this patient?

• <0.4

1c. There was a good femoral pulse but nothing below that. His necrotic toe was surrounded by area of erythema and oedema. Name 2 initial non-invasive radiological imaging investigation?• Xray• USS arterial duplex

1d. Your radiological investigation suggested that the lesions were amenable to angioplasty. List 4 potential complications of the procedure.

• Bleeding• Infection• Haematoma• False aneurysm• Distal thromboembolism• Vessel rupture• Contrast induced nephropathy • Contrast induced anaphylaxis

1e. The procedure was successful. The necrotic toe was amputated and the wound was healing well. He was ready to be discharged. The patient was not on any medication prior to admission. List 2 which should be started.

• Aspirin• Statin

Q2: You are the FY1 in A&E

72 y.o. male was brought in by the ambulance as he was found to be increasingly confused after having a brief episode of loss of consciousness.

He was pale, tachycardic, and hypotensive. His abdomen was tender with a pulsatile expansile mass. You suspect a AAA rupture.

Your SHO has trusted you to resuscitate the patient while he was trying to contact the surgeon.

2a. List 4 immediate actions and investigations you would do for this patient.

• Oxygen• IVI• Cross match• FBC• U&E• INR• Catheterise• Analgesia

2b. You managed to stabilise the patient for the moment. What imaging would you like this patient to have?

• CT aorta angiogram

2c. The patient underwent an open aneurysm repair. During the ward round, you found that the patient was known to have 5.4cm AAA. Name 2 indications to offer an intervention?

• >5.5cm• Rapidly expanding aneurysm (>1cm / year)

2d. Apart from rupture, list 2 other complications of AAA

• Emboli• Fistula• Inflammation• Acute thrombosis

2e. A few days later, the patient had haematemesis. What is the cause of this complication?

• Aorto-enteric fistula• Perforated peptic ulcer

Q3. You are the FY1 (again, duh) on call

Your SHO is tied up in a surgery. He has called you to clerk in and manage a 60 years old male who has come in with an acute ischaemic right foot.

3a. List the 6 symptoms and signs of acute critical ischaemic limb.

• Pain• Paraesthesia• Paralysis• Pulseless• Pale• Cold

3b. Name 2 broad causes of acute ischaemic limb.

• Embolic• Thrombotic• Dissection

3c. List 4 initial management and investigations

• Analgesia• LMWH 1.5mg/kg• FBC• U&E• LFT• Coagulation• G&S• ECG

3d. What are your 3 imaging options?

• USS duplex• CT angiogram• Angiogram

3e. Name 2 options to restore the arterial continuity

• Thrombolysis• Embolectomy• Arterial bypass

3f. A day following reperfusion, the blood results showed acute kidney injury. Why has this occurred?

• Reperfusion injury• Contrast nephropathy