A 63 Year old smoker with leg pain

A 63 Year old smoker with leg pain

1. Due to

   • Peripheral Vascular Disease
     • Circulation disorder due to narrowing or blockage of blood vessels
       • Earliest sign
         • Pain in the calf muscles
           • Increases with exercise and subsides with rest
     • Fontaine Stages
       • Stage 1
         • Asymptomatic
       • Stage 2
         • Intermittent claudication
           • Differential diagnosis of claudication
             • Musculoskeletal claudication
               • Arthritis
               • Chronic compartment syndrome
               • Muscle strain
               • Symptomatic Baker cyst
             • Neurologic claudication
               • Nerve entrapment
               • Nerve root compression
                 • Herniated disc
                 • Radiculopathy
               • Peripheral neuropathy
                 • Diabetes mellitus
                 • Alcohol abuse
               • Spinal stenosis
                 • Pseudoclaudication
             • Vascular claudication
               • PVD
                 • DVT
                 • Popliteal artery entrapment
                 • Vasculitis
                 • Venous insufficiency
               • Muscle pain on mild exertion
               • Relieved by a short period of rest
               • Early-stage peripheral artery disease
       • Stage 3
         • Rest Pain
       • Stage 4
         • Ischemic Ulcers or Gangrene
     • Causes
       • Atherosclerosis
         • Pathogenesis
           • Physical or chemical insults to the endothelial cell layer of arteries
             • The fatty streak
               • Stable and Unstable Plaques
       • Injury to the arms or legs
       • Irregular anatomy of muscles or ligaments
       • Infections
       • CAD
       • Venous problem
         • Deep Vein Thrombosis
           • Virchow’s triad
             • Stasis
             • Hypercoagulability
             • Endothelial damage
           • Signs and symptoms
             • Asymmetrical edema
             • Erythema
             • Warmth
             • Asymmetrical calf swelling
             • Asymmetrical localized pain
           • Complications
             • Pulmonary embolism
             • Post thrombotic syndrome
             • Acute GI bleeding
           • Investigations
             • Full blood count
             • D-dimer lab test
             • Liver function test
             • Urea and creatinine
             • INR
             • APTT
             • Venous duplex ultrasound
             • Venography
             • CT and MRI
             • Chest imaging
           • Causes and Risk factors
             • Immobility
             • Birth control use
             • Pregnancy
             • Smoking
             • Obesity
             • Genetics
         • Varicose Veins
           • Risk factors
             • Women
             • Aging
             • Prolonged standing
             • Crossing knees for long time
             • Obesity
             • Pregnancy
             • Family history
           • Signs and symptoms
             • Dark blue or purple veins
             • Spider veins
             • Bulging and twisted veins
             • Heavy feeling in legs
             • Burning and throbbing muscle cramping in lower legs
             • Itchiness and redness around veins
             • Pain worsened after standing for long time
           • Diagnosis
             • Physical examination and ultrasound
         • Chronic Venous Insufficiency
           • Causes
             • DVT
             • Phlebitis
             • Congenital defects
           • Signs and symptoms
             • Ulcers
             • Hyperpigmentation
             • Pruritis
             • Varicose veins
             • Pain
             • Edema
           • Diagnosis
             • Duplex ultrasound & venography
       • Vasculitis
         • Inflammation of the blood vessels
         • Mechanisms
           • Immune mediated vasculitis
             • Immune complex deposition
             • ANCA
               • Perinuclear
               • Cytoplasmic
             • Direct invasion by microorganism
             • Radiation, mechanical trauma or toxins
         • Clinical features
           • Fever / Arthralgia / Myalgia / Malaise
         • Classification
           • Based on
             • Size of Vessel
             • Anatomical Site
             • Histological Features
           • Large Vessel Vasculitis
             • Giant cell arteritis "Temporal arteritis"
               • Above the age of 50
               • Affects ophthalmic artery
                 • Sudden blindness
             • Takayasu disease "Pulseless disease"
               • Females less than 40
           • Medium Vessel Vasculitis
             • Polyarteritis Nodosa
               • Necrotising arteritis “immune complex mediated”
             • Kawasaki disease "Mucocutaneous lymph node syndrome"
               • Children below 4 years / Common in boys
               • Delayed hypersensitivity reaction
             • Buerger’s disease "Thromboangiitis obliterans"
               • Males / Heavy smokers / Below 35
             • Wegener’s granulomatosis
               • Necrotizing granulomas
               • Adult males
             • Churg-Strauss Syndrome
               • History of airway allergic hypersensitivity (atopy)
           • Small Vessel Vasculitis
             • Henoch-Schonlein Purpura (HSP)
               • Children
               • IgA and C3 deposit
               • After acute URTI
     • Risk factors
       • Modifiable
         • Diabetes
         • High cholesterol
         • High blood pressure
         • Overweight
         • Physical inactivity
         • Smoking or use of tobacco products
       • Non-modifiable
         • Age "Above 50"
         • History of heart disease
         • Male gender
         • Postmenopausal women
         • Family history
           • High cholesterol
           • High blood pressure
           • Peripheral vascular disease
     • Complications
       • Due to decreased or absent blood flow
         • Amputation
         • Poor wound healing
         • Restricted mobility
         • Severe pain
         • Stroke
     • Investigations
       • Imaging
         • ABI
         • Duplex ultrasonography
           • Anatomic information
           • Hemodynamic information
         • MRA
           • Angiography
         • CT
         • DSA
       • Physical exam
         • Ankle-Brachial Index
       • Blood tests
         • CBC
         • Blood urea / Nitrogen / Creatinine / Electrolyte
         • Lipid profile
         • Coagulation tests
     • Management
       • Drugs
         • Cilostazol
           • MOA
             • Phosphodiestrase 3 inhibitors
           • AE
             • Headache / Diarrhea / heat intolerance / Abnormal stool / Increased heart rate / Palpitations
         • Dipyridamole
           • MOA
             • Inhibit the cellular re-uptake of adenosine into platelets phosphpdiesterase enzymes
           • AE
             • Bleeding
         • Pentoxifylline
           • MOA
             • Competitive nonselective phosphodiesterase inhibitor
           • AE
             • Belching / Bloating / Stomach discomfort or upset / N&V
         • Aspirin
           • MOA
             • Cox 2 inhibitor
           • AE
             • GIT bleeding
         • Clopidogrel / Ticlopidine
           • MOA
             • Inhibit ADP
           • AE
             • Bleeding
         • Statin
           • MOA
             • Competitively inhibiting HMC-CoA reductase
           • AE
             • Hepatotoxicity / Myopathy / Gi upset / Cataracts
       • Interventional procedures
         • Angioplasty
         • Stenting
         • Atherectomy
       • Surgical procedures
         • Peripheral artery bypass surgery
         • Atherosclerosis endarterectomy

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