Professor’s Pearls: Vascular Surgery

Professor’s Pearls: Vascular Surgery




Section Review


Consider the following clinical problems and questions posed. Then refer to the professor’s discussion of these issues.


1) A 56-year-old man presents with a hx of left buttock and thigh discomfort after walking two blocks. If he stops and rests, the symptoms resolve in 2 to 3 minutes. The patient describes the discomfort as cramping in character. It has been present for 4 to 6 months and there has been no change in the patient’s exercise tolerance.
image Based on the presentation can you determine if the patient has an aortoiliac or femoropopliteal obstruction?

image Would your dx be influenced by the following? (1) you learn that the patient has diabetes, hypertension, and hyperlipidemia; (2) you determine that the patient has a 2+ femoral pulse and an absent popliteal pulse.

2) A 65-year-old woman presents following the onset of right calf and foot pain 2 hours ago. She denies any prior hx of claudication. On physical examination, the right foot is pale in appearance and cool to touch. The popliteal and tibial pulses are absent. There is decreased sensation over the distal leg and foot. She has decreased motion when asked to move the toes or dorsiflex the foot.
image Based on the hx, can you determine whether the patient has an embolic or a thrombotic obstruction?

image Is your dx altered if you subsequently learn that the patient is taking Coumadin for atrial fibrillation?

3) A 72-year-old man presents with a 2-year hx of left calf weakness after walking one block. The symptoms have been present for 2 years but have gotten worse over the past 3 months. The weakness resolves if the patient stops and rests. The patient has a hx of hypertension, smoking, and diabetes.
image Based on the hx, can you determine the etiology of the patient’s symptoms?

image Would your dx be influenced by the following? (1) you learn that that the patient has had a lumbar laminectomy; (2) on physical examination, the patient has a palpable left femoral pulse; the left popliteal, dorsalis pedis, and posterior tibial pulses are absent; and the ankle-brachial index on the left is 0.5.

4) A 62-year-old man presents with a hx of pain involving the left forefoot and digits. He has a 2-year hx of claudication, which occurs after one block. Two years ago he could walk five to six blocks before having to stop and rest. Risk factors include hypertension and hyperlipidemia. He has smoked one pack of cigarettes a day for 20 years.
image Based on the hx, do you have enough information to make a dx of rest pain?

image Would your dx be influenced by the following? (1) the patient has a 10-year hx of insulin-dependent diabetes mellitus. (2) On physical examination, the femoral and popliteal pulses are 2+ bilaterally. The dorsalis pedis and posterior tibial pulses are absent bilaterally. The ankle-brachial index is 1.65 on the left. (3) The patient tells you that the symptoms are worse at night. He cannot find a comfortable position, and often walks about his room, without any improvement in symptoms.

5) A 49-year-old man presents with a nonhealing ulcer on the plantar aspect of the right foot. He is a juvenile-onset diabetic on insulin. He also has a hx of hypertension. On physical examination, the patient has a 2-cm ulcer on the plantar foot, subjacent to the first metatarsal phalangeal joint. The right femoral and popliteal pulses are 2+, and the dorsalis pedis and posterior tibial pulses are absent.
image Based on the information provided, can you determine the etiology of the ulcer?

image Would your dx be influenced by the following? (1) The ankle brachial index is 1.69 on the right. (2) On physical examination, there is no palpable bone in the base of the wound. (3) Further studies demonstrate a TcPo2 value of 50 mmHg on the dorsum of the foot; the toe pressure is 45 mmHg. A radiograph of the foot demonstrates no evidence of osteomyelitis.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Professor’s Pearls: Vascular Surgery

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