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Okay, fine. Let me try. Oh, it's a bit weird, right? I haven't uploaded them as a pdf because it works better when it's a slideshow. But can you see that? Okay. Yes, I can. OK, fine. Cool. All right. Um, so Hi, everyone. Thank you for coming. My name's Sarah. I am. I'm not sure if anyone was in the cool when I was rambling on a little bit earlier, but I am, um, an F one currently working at the Royal Infirmary in Edinburgh. I'm working on a AM you jen med rotation. Um, and doing that for my next job and also doing an orthopedics job this year. Um, I what I do, I, well, things that I guess are relevant for you. I interviewed for the Med ed A FPs last year. So if anyone has, like, anything like that coming up, um, that's my email on the screen. So if you want to drop me an email or you have any questions, we've got any questions about the lecture or anything. I'm happy to take them. Um, So my lecture today is going to be on vascular, Um, based on the conditions that you have on Sofia. There aren't really that many. So, um, it's actually quite a straightforward, um, list. And I expect I'm probably not going to teach you anything that you don't already know. Um, they're all conditions that definitely came up in third year. So I think it's just, like, a little bit of, like, revision, um, and then just reminding you of like what the managements are. And, um, we're just going to go through, like, a couple questions. Um, so, yeah, we'll we'll go through all the conditions, and then the majority of this, like, the procedures come up in the stuff that we go through, um, bar, like one or two, But, um, yeah, hopefully covers everything. Um, So the way that I thought we'd start is I have three s pas. Um, I don't really know how much I don't have a mentee thing, so I don't know, like, um how interactive it can be, But if I just give you, like, a minute for per question, um, and then just write down an answer. Just commit, Even if you don't know guess, um and then, um I won't give you the answers now, but we'll go through them at the end, and I'll go through an explanation for all of them. So, um, I'll just give you a minute to read through and do this one, and then I'll switch to the next one. Um, and then we'll just do those three and then get started with the actual content. Okay, So I'm just gonna go on to the next one. I think there are a couple spelling errors in these, but you'll have to excuse those. That final option should actually say, Am I, um I think I must have when I copied the slides, made a mistake. So option e should actually be Am I cool? Okay. And then this is the last one. Okay, right. I'll finish their, um and then we'll go through the answers at the end. So, um, I don't have that many slides because there's not that. Not that many things to go through, which I'm sure you'll be pleased about. So hopefully we can kind of rattle our way through, um, and it won't be too long and boring. Um, so the first thing that we're going to go through is aortic aneurysms on Sofia is specifically specifically says Triple A, but I will go through like, two different things. So, first of all, you've got two different types of aneurysm. You either have a true one or a pseudoaneurysm. So a true aneurysm is basically when the wall of the arteries forms the wall of the aneurysm. So you either get saccular or fusiform. So secular is when it, um sort of like blebs out on one side. Um, and then fusiform will be when it's expanded sort of evenly on both sides of the artery. Okay. And then a pseudo aneurysm is when you basically have leakage of blood out of an aneurysm into the surrounding tissue. And then what keeps the the like blood in a specific space is the pressure of that surrounding tissue on it. Um, so when I first like, try to understand this because this just seems like it's like a hole in an artery and it's kind of like pouring out. My understanding of it is that even though like pressure in an artery is hi, um, there is a form of connection between that collection of fluid outside of the artery and within the like main Lumen. So there is still a connection, and you still get a passage of blood between the two, which is what makes it slightly different to a hematoma, which is just like a collection of blood, which is a bruise. So, um, if you have a look here, this top picture is, um, like it doesn't look like a bruise. So that's, um, a pseudoaneurysm from like, repeated ABGs. And then you've got, like, a penetration in the wall of the artery causes a little hole, and then the blood bleeds out, but it's contained within a specific area by the surrounding tissue. But that blood kind of has, like, can move sort of back I/O of the circulation, which obviously is quite a big risk factor for things like, um, clots and whatnot. But that's, um, that the best image I could find that showed how it would look different to a hematoma. Um, it can also happen in like the femoral artery. So, for example, if, like, um, like with interventional radiology and things like that, if you're having to do, like, repeated, sort of like punctures in the in the artery wall, um, the blood's going to spill out and, like, the surrounding tissue will form the wall of a hematoma. Basically, Um, but yeah, So there's your two things. So your definition of an aneurysm is something that's 50% more than the normal diameter of the vessel or is just bigger than three centimeters. Um, so you've got two different types. You've either got a thoracic aortic aneurysm or an abdominal, uh, so a little bit confusing. So the it's like 100% in either section. So 60% of thoracic aneurysms are in the ascending aorta and 40 and the descending. And then when you look at abdominal aortic aneurysms, 80% of them lie below the weather. Renal arteries sort of bifurcate off to go and supply the kidneys. So in your thoracic aorta, you've got your aortic root, so the bit that comes out of your left ventricle and then the ascending aorta, okay. And then you have the descending aorta, which is after the branch of the left subclavian. So, um, things that predisposed to aneurysms in the aortic root and the ascending aorta are like, um, connective tissue, things like mar fans or Ehlers Danlos or bicuspid aortic valves. Because obviously, you have, like, a bit more sort of laxity in the in the in the tissue, um, and then also, like, familial things, like hereditary things. Um, and then in the descending aorta, it's more of the stereotypical stuff. The stuff that predisposes you to triple A. So atherosclerosis, um, and cystic medial necrosis or your two most common things that cause, um, descending aortic aneurysms. So this cystic medial necrosis is basically where you've got basic fills that accumulate within the vessel vessel wall, and then they kind of start breaking down things because their white blood cells and then you're gonna get these kind of cystic like lesion's, which weaken the integrity of the wall and then obviously, trauma, um, and then your abdominal aorta is just things that are way more familiar. So atherosclerosis, which is obviously caused by things like smoking, higher age, hypertension, hyperlipidemia. If your male, um, family history if you drink alcohol, um, if you have a high red meat diet, um, all the things that predispose you to cardiovascular diseases, you can have some inflammatory causes. So, like some i G antibodies that can attack, um, and then infections. So, um that. That kind of reminded me of like, when Am Assam always says, like, um, was it infection, inflammation and malignancy? Just that there is no malignancy there. So as soon as something is inflamed or infected, um, there's there's more weakness in it, and with more weakness, you have a higher risk of it becoming an aneurysm. Uh, so, yeah, just just sort of some formalities, then. Um, symptoms. So your thoracic aortic aneurysms, a lot of the time can be a symptomatic. In fact, both of them can be, uh, the things that cause the symptoms aren't necessarily like the aneurysm stretching itself, but like the effects, it has another thing. So within the thorax, it can put pressure on, like depending on what it's pushing on, you can get what feels like back pain. Dysphasia cough. Uh, depending on which direction is going and what what, like adjacent structure is pushing on, um, in the previous one. Like I said, when it's like the ascending aorta, like just here at the bottom, um, that can also have an effect on like your aortic valve so it can predispose you to aortic regurgitation, and then you'll have the symptoms of aortic regurgitation. So with aortic regurg, you have your blood coming out of the heart. But then obviously you get, like, backwashing of it. So you don't have as good a cardiac output as someone. It doesn't have a aortic regurgitation. So your symptoms are going to be things like shortness of breath, um, pre syncope or syncope, because you just don't have that cardiac output, um, angina. If you're not getting the supply to, like, blood supply to the heart. And then with just like any strain on the heart, it predisposes you to arrhythmias. Um and, um, depending on where it could be, you can also sort of get, like, altered, um, strength in your like, break your radio pulses, which is kind of similar to like an aortic dissection. But it's all very dependent on how positional the aneurysm is. Um, and then in terms of the thorax, um, you can't really do an ultrasound of the thorax like you have to do the specific ultrasound, which is like an echo or a transesophageal. Um, ultrasound. So that's a toe. Um, and then your next thing would be a CT, um, with your abdominal aortic aneurysms is very similar. Um, they can be a symptomatic, but just found coincidentally, like if you find a pulse, it'll mass on examination, and then you have the pressure effect again. But this might cause epigastric pain or back pain. So just like things people might present with that Oh, they got, like, a pain in the epigastrium. Like, just always think about, like, differentials that you might be more biased towards. So things like gored or ulcers like, um, it's not that often that you include a triple A in your differentials, but it actually comes up a lot more often than you think. Um, and then obviously, if it's a ruptured aneurysm, you're going to have, like, severe pain. Patient is gonna be in hyperkalemic shock. They may not be conscious, um, and has pretty pretty high mortality. Um, and then your imaging is also going to be an ultrasound. This time it can be an abdominal ultrasound, a ct, a CT angiogram. So that's just a CT that specifically looks at vessels. Um, and then, um, interestingly, lots of these are actually spotted on Abdo X rays because you get quite a lot of calcification in them because they're asymptomatic people sort of sit with them for quite a long time. Um, and then they get calcified. Um, and then they pop up on an ab do X ray when someone gets admitted for something else. Really? Um, so, yeah. Um, now I put that in there. Don't always. I think this is quite a common one and sort of one thing that I've noticed more as an F one, like every man and his dog comes in to a and e. And am you with the UTI? Um, and then you get like, quite often the differential. Is that a renal colic? They've got really bad back pain. And I actually had a patient with this the other day and we thought a renal colic. And then it was like the day after, um, an aortic aneurysm actually became, like, quite a high differential. So we had to then do a CT. Um, so just be mindful of, like, common. And also don't just disregard things as well. So especially in questions as well, if you, like, stressed doing multiple choice things, um, I think it can be just like a good one just to be a bit mindful. So, yeah, so those are your investigations? Um, Now, in terms of management, everyone, like all men over 65 over, are invited that year to have a one off screening. An ultrasound screening. Um, and then, depending on that, you have this flow diagram. So if the aneurysm is found to be between three and 4.4 centimeters, so remember, I said, like anything above four is considered an aneurysm. You'll do another scan in a year's time. Um, if it's between 4.5 and 5.4, you're going to do a follow up in less than three months time. But in the meantime, you're going to want to do something so conservative and medical management so conservative. Things are going to be like weight loss, smoking, alcohol, diet, um, and then medical things. Statins, aspirin, making sure their BP is well managed if they're hypertensive, if not, maybe starting them on some anti hypertensives. If you found that at the time as well, um, and then scan them in three months, Monitor it. If it's above 5.5 centimeters, that's for surgery. So, um, not necessarily on that specific presentation. But people be referred. I think it's within, like two weeks. Um, it goes down that kind of accelerated pathway for either open aortic surgery for more fit patient's or IV are so endovascular aortic repair. So that's like the patient's are slightly more frail. Um, then other things that might like that would cause you to do like surgical intervention is if it's ruptured. Obviously, he's got very high mortality. But then, if they're symptomatic, so if they get in pain from it or other symptoms, um, if it's above 5.5, like I said, or if it's above four centimeters, and in the last year it's grown by more than a centimeter. So, like you scan it once, it's like above four or below four, and then you scan again, and then it's a centimeter bigger regardless of where you started. But it always have to be over four the second time. That's also an indication for surgical repair. Um, so that's your management of enable to can urine so pretty straightforward, bit boring. You kind of have to learn a flow chart, but hopefully that's pretty clear. And, you know, like what to do at each point. Um, so yeah. Okay, so next thing is, um, aortic dissection. Um, so your definition, Um, not that these ever like, Not that anyone ever ask you to define this in, like, finals or in paces, But it just actually comes in, like, quite handy doing what it is. So you get a tear in the Tunica intima. So you're in a layer of the blood vessel, which means that blood that's flowing through the able to at a high pressure then has enough sort of force in it to create a false lumen in the Tunica media. Um, and then we'll sort of rejoin back into the main Lumen, Um, so two types type a type B. Um, that's the Stamford classification. I only ever really see that come up in M. C. Q s. I remember when I was doing it last year. And like now, um, this is slightly more detailed, but I think your Stanford classification is sufficient. Type A is everything in your ascending aorta, type B is anything in the descending aorta. So that's distal to this left subclavian. Um, artery? Well, the origin. Okay. Put that little our there, so you're two definitions, and you probably already know a lot of these things from my third year, but I think it's just good to be reminded of it, So this is not a very aesthetically pleasing slide. It's quite list E, but I would just go through it. Signs and symptoms Tearing chest pain radiates to the back unequal BP and arms, depending on where your dissection is, because then you'll have that lower. So if the blood isn't in the main Lumen, it's in this false loom, and you're not gonna have as higher BP in the actual Lumen. So if if blood's branching off and going into like a branching artery, the amount of blood going into that is going to be lower than let's say, like the bit that branched off the artery, where it didn't where it had a normal amount of blood in it. So you can have unequal blood pressures and arms, Um, week distal pulses, so like they might might be strong in one or, um, quite weak in the other. Or you just have, like, a discrepancy between the two. Um, always, like, trust your judgment. Um, like I think when things are normal when you're examining patient's just like in terms of, like, actually helpful things for when you're an F one, Um, you're pretty good at examining normal. Like normal. I say normal, like patient's without any findings. Um, I feel like you practice enough in your mates and things and you practice enough on like patient's that don't have significant positive findings that when you're actually like examining someone and your query er and you think, Oh, that does feel a little bit weird. Like always trust yourself. And I think that that happens quite like it happens quite a lot. And you just have to realize that you're pretty good at, like finding the norm. But even just with, like these little things, I think it does come up a lot more than you think. Um, aortic regurg, depending on whether dissection is if it's close to the aortic valve, similar symptoms to like what I said for the thoracic aortic aneurysms. And then if you have impaired blood flow like cerebral blood flow, you're gonna get neurological symptoms so it could be hemiplegia headache, neck pain, like anything neuro in the head like think of that as well. Um, investigations, Bedside blood's imaging? No other like specific special tests. But blood pressure's E C G, um, Bloods. You're going to want to do full blood count using these LFTs because using these and LFTs, I know like these role of your tongue, but always like trying, have rationale. If you've not got as good a output coming from the heart, you might have reduced profusion term organs. So using these, if there's reduced profusion to the kidneys. LFTs If there's reduced perfusion to the liver, um, lactate is just a measure of ischemia. So if you just reduce profusion anywhere in the body, um, and then group and saving cross match If you say those in paces, um, it just like it makes you look like you know what you're talking about. Like someone might have to go to theater if it's bad. If you've done a group and save already like if you stay in paces, it just no, you just show that you're thinking like a bit more like in the future. And when it comes to actually being an F one, Um, doing these earlier on like really helps because then, when like patient's get more unwell. They're a bit more like hypertensive. You can't get blood of them. You're not stressed about trying to do another group and safe Um, and then your imaging is on a chest X ray. You're going to see why didn't mediastinum because you've got this new Lumen and then you'll do CT or MRI. Um, and then if someone's pretty unstable, you can't really take them to see T. So you'll just do a transthoracic echo. But if someone's going to theater, it's pretty rare that someone goes to theater without having a CT or more of like an advanced form of imaging. Um, so yeah, um, the ways that you manage it manage the BP. If the BP is too high, there's a risk of rupturing things. So you're gonna manage it with beta blockers if it's a proximal dissection, So it's like Type A, um, you manage it surgically. If it's distal, it actually just bed rest and BP management, which I thought I typed in there. But I haven't evidently, which always makes me feel a little bit uneasy. But there's evidence, and that's just what they do. So It's actually just like conservative. In that case, we'll conservative and then like medical in terms of managing your BP. Um, so, yeah, aortic dissection. Um, I think that is everything for that one. Cool. Um, I can't actually see. I think if I go back onto the chat, um, I'll be able to see the question, but what I'll do is I'll just go through the questions Now, Um, go through the slides now and then I'll go and have a look at the questions at the end, and I can try and answer as many as I can. Is there any popping through? Um, okay, so the next thing DVTs so also horribly common, Um, you get a swelling somewhere in the venous um, circulation, which means that blood can't easily drain out of the leg. So it pulls. Um, it's venous blood, so it's got loads of stuff in it that you don't want. Um, carbon dioxide toxins. It becomes irritate Ivanov. Um, that irritates the tissue. It becomes red, it becomes swollen. Um, exactly like that kind of so risk factors that everything is a risk factor for DVTs. Everyone in hospital is on vte prophylaxis. Everyone has a risk factor. Even if you're young and fit, you're in a bed and that immediately makes you at risk. Um, so just a big old list of them age comorbidities hospital admission, systemic infection, obese abdominal surgery, cancer, pregnant estrogen containing drugs, Immobility, uh, phlebitis and varicose veins. H h s. So if you're really dehydrated also people that own D k A. Like horribly dehydrated. So as soon as you're dehydrated and dryer at risk of this, um, family history thrombophilia xyz i B d s nephrotic syndrome is They're kind of just, like, quite like, not necessarily systemically unwell. But you're you're pulling surgery loads. I'm going forever. But I thought I'd just, like, limited to that. So symptoms you all know what it is like. Well, actually, quite a lot of them can be a symptomatic, but read erythematous painful, superficial venous distention because you've got a clot. Your blood's not being able to like leave, so you kind of get like, like, temporary kind of varicose veins as well. Um, I think the thing that becomes difficult about DVT is like when you're clinically actually like trying to debate with yourself whether it actually is. So lots of times you're looking at something and you're thinking Is this cellulitis or is this a DVT? Um, and you just sleep a lot easier if you just do a d dimer and ask whoever's taking you over to chase the results of that, because, I mean, that's just the way it is. So I think rather like the hard bit isn't like like you know, the symptoms of the DVT. But when it actually comes to like clinical stuff, you end up coming and our ring being like, Oh, is it is. And especially when it's cellulitis and like cellulitis, which is, like, quite profound as well. Um, then thing, other things that cause a Dema. Lots of people just sort of have red, um, fragile skin on their legs, especially if they're vascular paths. And then they also might have quite a dermatis legs because they've got cardiac failure. So sometimes it's like a bit of a combination of different things, and you're just not quite sure. So, just like differentials to consider and then ruptured Baker Cyst Baker's cysts. Um, they're really quite painful, though, Um, and they'll be like behind your knee. So a little bit of a different presentation, but just some things to consider when it comes to actual practice, I think, um, so yeah. DVTs Now, how do you investigate and how do you manage? Um, so you need to calculate a well score. So if the well score is zero or one low risk, if it's two or higher, it's high risk. So this is your thing? How to calculate? Well, school. I think it would be pretty mean. Like it didn't come up in my finals. I don't really see it coming up where you have to calculate it. Often they give it to you in the question, Um, in practice, you're never calculating stuff of the top of your head. You're just using an app. Um, so I wouldn't worry about memorizing it. Um, I think they'll probably give you the value in the question. Um, so if it's 01, it's pretty low risk. You're going to do a d dimer. Um, if your d dimer is positive, you then want to go and do an ultrasound of the leg. Okay. If you do a d dimer and the D dimer is negative, then consider another diagnosis. This quite I'm not gonna say rarely happens. But like a lot of things can cause an elevated D dimer. Assume a lot of the time end up going down this way. If it's two or above, you're going to do an ultrasound of the leg. If it's a positive ultrasound, so you find a blockage, you're going to give them a doe AC. If it's a negative ultrasound, you're going to want to do a D dimer. And then you kind of go to the left hand column and go from there. Um, if you do a d dimer and then the d dimer is negative, like so you've done an ultrasound. The D dimer is negative. No, you do an ultrasound, the ultrasound is negative. So then you go and do a d dimer. But the D dimer is negative. You got two negative findings, but you've got really like it's very high clinical suspicion. Um, then you just, like re scan them in a week's time. Um, but I doubt that they're going to put something in that that's like convoluted. Um, but just just for sort of like awareness. Um, if those two first things. It's like a diamond. Ultrasound can't be done within four hours. You're gonna give them an interim Duac. Anyway, um, just to cover, um and then if it's an ultrasound, you're gonna want to try and get one done within a day. Um, this is more sort of like re sourcing kind of things. You can't find a finder or like, there's no space on the list or whatnot. Um, but I expect they won't put that in a question. Um, like, in finals or in places. Um, so once you've established that, you're gonna treat them for a doe AC if it's a provoked DVT. So if there's something that's caused it So immobility, surgery, pregnancy, um, like systemic infection, like basically all of your kind of, like risk factors, it's going to be three months. If it's unprovoked, then you're gonna give them six months of a dose pack. Um, now, if it's unprovoked, that's a bit like that's a bit quite like you're a bit concerned. Is that why it's unprovoked? Likewise is just randomly happened. So in most cases, you're then going to do a CT abdomen, pelvis in these people to look whether there is a malignancy that might be causing this. So cancer is a really high risk factor for giving it getting a DVT. Um, and lots of people just like go for quite a while without knowing that they've got cancer. Uh, so that's another thing. It's like a thing in finals or in pace Is that if you say it just makes you look like you actually know what you're talking about? Um And then obviously you've got a risk of a D V T convert like going to a PT. So if you if you've got a history in paces and someone's like saying, Oh, like you're thinking P DVT symptoms, etcetera, texture. Always ask about the P symptoms. So, like shortness of breath, hemoptysis isse chest pain. Um, just just show that you're excluding it because you need to, um, so, yeah, those your investigations and your management for DVT's. Um, hopefully, it's clear. I know there's quite a lot of information on there, but just I don't think they would do like too many weird loops will either be like they have one or they don't and I think be relatively obvious. Um, this is a bit more of, like a different flow diagram. It's got a bit more information. It contains the majority of the information from the previous slide. I'm not going to go through it. It's just there. If any of you want to go, I've sent the slides along so hopefully they'll be distributed to you so you can just go through it and have a look. Um, and then often, like, if you come up with a question or whatever, just go through it and see if it matches up. Um, and, um, I found, like finding these things actually just helps. I have screenshots of them on my phone. Just makes life a little bit easier when you're actually having to do work. So yeah. Um cool. OK, so one of the procedures is an A BP I. So, um, what does it show? Well, what does it measure? It's a ratio of your ankle Systolic BP to the break your systolic BP. Right. So the ankle pressure goes on top and the break your pressure goes on the bottom. If they're equal pressures, you get a value of one, because 100 20 divided, 120 is one. So no peripheral vascular disease. Then this is like the way that I think about it in my head. If you've got a small value on top, I the the ankle BP is worse and you're dividing it by a normal number is going to be a smaller number divided by the normal number. So you're going to get a smaller number overall. So and you you're only going to get, like, worse BP in your ankle if you've got peripheral vascular disease. So the smaller the ABP I like the more like that's like peripheral vascular disease territory, right? Just like a bit of a logical way to think about it. Um, I'm sure a lot of you probably know that, but I find it helpful just to kind of think through things logically, especially when you're stressed trying to answer questions in the exam. Um, then there's lots of different kind of like boundaries for things. But in general, if the A BP I is less than 9.5, sometimes they say 9.3, you've got severe, like peripheral arterial disease. Um, then everything in between that. So from 9.5 to 1. It's kind of like worsening as it gets smaller. And then if it's above 1.4, that's when you've got, like, what you're gonna have, like a bigger number on the top, divided by a smaller number. So that's when you get, like, calcification of vessels. So, um, so that's when, like your you still actually need to refer them to a vascular clinic or whatnot because calcification of vessels is also like a vascular issue. So, um, you want it within the range of, like one you want it to be one. But then like the lower it gets, the worse the vascular disease. It goes above 1.2. You've got calcification and vessel hardening, which is also bad. So that's what an ABP I measurement actually shows you. Um, so if we talk a little bit about peripheral vascular disease, atherosclerosis and arteries, which forms occlusions, which I'm sure you all know, talk a little bit about the signs and the symptoms. So if it's mild, you're gonna get claudications, um, on exertion or at rest. Um, a lot of people that, like that have really quite profound Vascular disease don't tend to be that mobile. So then claudications isn't necessarily the thing that they present with because they're not really doing sufficient amount of exercise for them to get pain on exertion. So they'll tend to present when they're getting pain at rest, which is then just even worse. So they present an even worse point. Um, that's with mild stuff. If it's severe, you're going to have, like, impairment of your circulation, right? So you're going to get like ulcers. Gangrene if you get poor profusion. Two places If gangrene gangrene is just like bad, um, supply of, like, blood and oxygen. Then if that area gets infected, um, with bacteria, then you get what's called wet gangrene. Um, and then you get reduced pulses, um, skin atrophy, hair loss, cyanosis. Um, you can get impairment of sympathetic nerves, which causes excessive sweating and then, if effect, depending on what? Like part of the vasculature effects. If it affects the like the distal aortic disease, you can get erectile dysfunction. Um, so lots of different ways that it can present with, like increasing severity investigations. I like to do it. Bedside blood imaging, special tests. I like lists. It makes things so much easier. You look so much more on it when you're talking to someone. Um, so bedside things, BP, E c g do a vascular exam Burgers angle is when you lift that leg up to 90. Do not 90 public, quite stretch to, like, 20 degrees. And then there'll it goes pale because, um, like, you just have poor vascular supply to him. Um, so those things, if there's any lesions on the foot or any ulcers, say you're going to do some swabs, just makes you look like you're thinking if you start someone antibiotics before you swab stuff, just like it just makes things a lot more difficult. Doesn't make things as accurate. Then, in terms of bloods, you're going to do full blood count using these lipids HBA one c So lipids in HBA one c are like things that contributes to peripheral vascular disease. So diabetes hyperlipidemia, um, you might might want to do an esr ns crp, like crps aren't necessarily just elevated in infection. Um, like I know like UTR pneumonia. Um, if you've got arthritis, um so like infections that aren't necessarily as visible, like, um symptomatic, um, and then platelets clotting. See whether that's a bit deranged. If you think someone might be having to go to Theatre Group and save cross match that kind of stuff, um, then you're gonna do a CT angio or an M R N g o um, and then digital subtraction arteriography just like special ways of like imaging the vessels, Um, and then a duplex ultrasound scan, which is just an ultrasound with color on it. So the you can see which kind of like blood's going where, um, and you're due. If you're ever in doubt about like a less invasive one of those CTS invasive. But it's like you got exposed to radiation or not. If you're ever in doubt about what investigation to say for vascular questions, just always say duplex, um, ultrasound scan, because you've got a pretty high chance of getting right, and then we'll do an A BP I. That's a special test in this case, um, management structure again. Conceptual conservative Medical, surgical. So you're conservative stuff is going to be like weight loss. Reduce alcohol, smoking cessation, exercise, medical things, statins. Antiplatelets optimize all of the other cardiovascular risk factors to like manage their BP. Um, manage their like high lipids. Um, I mean, that's what the statins for. But, um, and then your surgical things are angioplasty, which is when you just put a stent in a vessel, expanded and just push the atherosclerosis to the side. Um, other types of stenting you might want to bypass and colectomy. So if it's an embolus, So if it's something that's fired off from somewhere else, got stuck and then cause an occlusion, you might just want to take the embolus out. Um, and then in severe cases, amputation always go for, like, the amputation of least like effect. So, like below your joints and things like that. So go below the knee knee. But you just have to remember you have to have enough, like, healthy bit of like Lim for the actual stump at the end to be able to heal. So it's just a bit of a balance. Uh, so, yeah, so that's peripheral vascular disease. Um, right. How long we got? Fine. I'll try not to ramble on too much. We're nearly there. So emergencies acute ischemic glim. So, in terms of, like order of vascular disease, you get intermitted claudications, which is like bad, but not there all the time. Then your next worst thing is critical Limb ischemia. Um, so you get a schema in the limbs. But it's not to the point where you're like your limb is in danger, and then you've got acute limb threatening ischemia. So this is the word worse. This is a surgical emergency. This is what I'm going to talk about. Now, this is very painful. So these are your like, six p s pain, pulseless pal or power loss Parasthesia perishing lee cold. Um, so it's actually surprising, actually. Um, like you might think that it's like, really that when this happens, it's really rapid, but that then there tends to be, like, a fair bit of like, um an aming and our ng as to whether, like, someone actually has sometimes in the acute ischemic limb or not. Um, but you know these things I'm just like it's just revision for you. I think so. These are your six p s for your scheme, Iqlim. How are you going to manage it? So you either have medical management or surgical, so medical is you can put someone So there's obviously a blockage somewhere that's caused critical, like arterial ischemia to the limb so you can put people on a heparin infusion. Um, now, heparin infusions are really difficult to have it. Well, not difficult to manage, but they're just, like, really quite high maintenance. You have to do a lot of bloods on these patient's you have to keep doing regular um, a PTTS. You're like clotting things just to see what's going on with their like clotting cascade. These people also be quite a lot of pain, and when you're in pain, don't really breathe as well. So remember, give them analgesia, give them oxygen if they're sat too low because they're in pain. All of these other little things that go with it, um, and then surgical management. If it depends on if it's an embolus or a thrombus, you don't necessarily know like you can't necessarily guess what that is based on. Like, um, when someone presents. But like in an M. C. Q. There might be something in the history that suggests that this is is an embolus, or this is a thrombus so embolic things you can do an embolectomy thrombolysis or bypass. So either take out the throm pus. Um, you take out the embolus, you try and dissolve the embolus. Or, if there's no hope, you just have to, like, put a vessel around it to bypass it entirely. And then for thrombotic things you can thrombolysis it. So, like, destroy it. You can put a stent in and do an angioplasty and just try and squash it. Or again, you might have to do a bypass. Um, so, yeah, just kind of like think logically with what the management of it is. So that's acute limb ischemia. So that's the surgical emergency, which is the worst one. Um, fun. I think we have, like, three more conditions, so hopefully I'll be finished by seven. Um, and you can have the rest of your evening. So varicose veins. So the way the varicose veins work is that there's an incompetent valve somewhere in the venous circulation in your lower limbs. Which means that, um, blood that's in the deep venous system can't continue to, like, get out of the legs. So they have to take it because there's like a bad valve, Um, and it's getting stuck and the blood is stagnating in the bottom bit of the limb. So your blood then tries to take a path of least resistance, which means it ends up going into, like, the more peripheral into the more superficial vasculature of the leg. And then that high BP blood is going in there staying pretty stagnant. And then your vessels are dilating, and then you get like venous hypertension and dilation of the more superficial vessels, which gives you your varicose veins. Okay, so the vote, I think it's like 98% of them are idiopathic, and then 2% are due to something else. So, DVTs. I mean, you've got, like, a very obvious blockage, which means why blood has to go another way if you got pelvic mass. So fibroids are very masses or pregnancy. Um, also, if you've got arteriovenous, fistulas or malformations also can cause it. Um, so, yeah, um, in terms of the way that they present, they can be a key itching. Uh, you've got a lot of stagnation, like stagnant like like dirty blood. Really? Like you've got a lot of toxins and things in there, so skin changes ulceration thrombo phlebitis. If that blood is like irritated to the blood vessel walls. Your gold standard is a duplex ultrasound scan. So here you go. Just guess it, and it's probably on there for investigations. And then your management is conservative or surgical. In this case, um, so conservative things. Weight loss, exercise avoid risk factor. So, like standing lots like chefs, surgeons are like the two professions that are have the most varicose veins. Um, you cannot put compression stockings on someone who's a BP. I is less than 0.8. So if you say I'm going to put like compression stockings on this patient, just say I'll have to check an A BP I first. Because if they got really bad peripheral vascular disease, um, or like uh, like peripheral arterial disease, you don't want to like occlude the vessels so much that the like blood can't even get there. So just remember to do an A BP I, um So there's your conservative things. These are very repetitive. It's like the risk factors. Um, so it's It's pretty similar in vascular, then your surgical things, like the criteria for surgical intervention, and these are the nice criteria are if someone symptomatic if they have skin changes if they have, uh, superficial vein thrombosis, so if they're getting blocked or if they've got a leg ulcer. So I mean, being symptomatic isn't actually like like, lots of people will get achiness from varicose veins, so it's pretty low threshold. So then you can do vein ligation or stripping or revulsion. So you basically take them out. You can fill them with foam, which is foam sclerotherapy, which, which means that the blood stops going through the more superficial vasculature and has to stay in that deep system and eventually just gets forced back through, um, or thermal ablation, which is where you put something really hot in the vessel. It like shocks the vessel damage, is it? And it causes it to close off. So, yeah, so those are your surgical things. Um, Now, this is a very ugly slide. Lots of words. I'm sorry, but arterial and venous ulcers and I was put neuropathic on the other side. You probably all very like you've got finals in like a little while. You know this already so arterial Things are like arterial ulcers are sort of small, deep incisions with well defined borders. They don't look particularly necrotic. They tend to happen in places where people have already hurt themselves a bit, um, and they don't really like. They don't heal very well, because if you've got, like, peripheral arterial disease, your blood supply to your feet isn't great as it is, So you don't really get, like, good perfusion, so it can't really heal too well. Um, so that's why it's associated with peripheral vascular disease. Um, then I'll go through the investigate, so the next line is investigation. So it's just the same again and a BP I a duplex ultrasound scan and a CT or an MRI angio. So you just want to like you want to see the vessels and then the management again. It's all the same lifestyle. Things are conservative. Medical things are statins. Antiplatelets optimize their risk factors. So BP and blood glucose and then angioplasty. So, um, fixing the vessels or bypass grafting? So going past blockages. Um, so that's your arterial Venus. They look more stuffy. They look more gross. Um, you don't have as good like you get impaired venous return. So yet again, you've got like blood pooling in the feet. That means white blood cells stick around a bit longer than they should. And then they get activated because they're hanging around looking for something to activate them. And then they release inflammatory markers, which causes a bit of like necrosis. And that's why they just look slough e and executive. And, like gunky. Um, your investigations are the same again. A BP I Ju Bilic's ultrasounds scan. If there's something that if it's seeping, swab it, and then if it's a young patient, you want to think why they're getting a venous ulcer so it could be a thrombophilia. Or it could be like a vasculitic disease if there's a strong family history. So think about screening for those things, especially if in like the M. C. Q. S, it comes up like that. It's a young patient, Um, and then you can do compression bandaging. Um, the A BP. I has to be above 0.6, and often these happen with varicose veins so you can treat the varicose veins to prevent these from happening. Um, neuropathic thing. Neuropathic ulcers aren't part of vascular, but very quickly tend to be because of diabetes or B 12 deficiency. So if you fix that, you're more you'll well, not necessarily fix it. But if you try and manage it well, you might improve their peripheral neuropathy. Um, so people don't tend to feel these because they've got peripheral neuropathy they might have, like a glove and stocking distributions. I have numbness because they've got, um, diabetes. Um, and they're a bit more punched out these ones. So basically, measure the HBA one C or random blood glucose. Do their B 12 levels. Swab it if it's seeping, or if there's anything you can swab. You might have to consider doing an X ray if the if the ulcer is near a bone because there's a high risk of osteomyelitis. Um, and it's actually surprising how often that happens. And then just managing those manage their diabetic feet, optimize their diabetic control lifestyle things get them to look after their feet basically. So those are ulcers? Um, just a couple of pictures so you can see this is like a little bit more like Slough e and, like, not quite well defined, whereas your arterial one especially one here, Number two. It's very well defined. And then your neuropathic also like it's going to be quite hard skin as well around it, and they just like the patient's, won't feel it, whereas the arterial once hurt. Um, so, yeah, and these take ages and ages and ages to fix. If you're able to fix them, lots of people just sort of live with them for a long, long time. Um, and then final thing is gangrene. So, um, gangrene caused. So basically, you have blood supply that is impaired. Well, blood supply to the tissues is cut off, so if it's dry, grand gangrene, the vessel like the toe or whatever, will become dry and it'll shrink. It will go black and lots of the time. Actually, the management is just wait for it to fall off. And then if it's wet, that happens. But bacteria invades, so then it swells and then it gets wet and it smells bad and it gets infected, and there's a risk that someone becomes septic. So how does it present? It would be called. It will be painful. It'll be read. It might be swollen. There might be something seeping from it. If it's infected. Patient's might become septic. And if they're really septic, they become fused and delirious. Um, and then your management is antibiotics. Quite difficult to manage this because, like, how is the antibiotic gonna get there with the blood supplies and that Great. Anyway, so it's kind of a bit of a battle. Uh, you might have to do surgical debridement, so just, like, wash like, clean it out in theater. Maggot. Debridement actually happens quite often. Um, they just have, like, these little tea bags full of maggots, and they put them on stuff, and then they just kind of like clean stuff. Bit freaky, though. Hyperbaric oxygen therapy, which I think is quite boogie one. I don't think that often happens very much in the NHS, But basically, if you put some, like put the body in somewhere with lots of oxygen, it means that like it oxygenates that part of the body. So, like, that's basically what blood is trying to do. So you're just kind of forcing oxygen in another way so that things can regenerate bit quicker. And then if it's really bad, you're going to have to do some sort of surgery like I've listed that before. Um, so that's gangrene, right? Um, I appreciate that. It's seven o'clock, so I will just power through and explain, um, these SBS to you. So, um, a 52 year old woman is in hospital after being admitted for an elective umbilical hernia repair. She's got past medical history of type two diabetes. She was a smoker. She's got I BS. She's day to POSTOP. You noticed that her right calf is erythema tous. It's tender, you've got an elevated D dimer, and the ultrasound shows that you've got a DVT so your she's had the she's had surgery, so it's provoked. So if it's provoked, you do three months of a dose pack. So it's three months of apixaban. Um, and, um, whenever anyone has started on a dose pack, this will tend to be like the F one's job. You have to counsel them. So, um, lots of places have like a list that you just print out from the Internet, and you have to go and tell them, like if you fall, you will bleed more easily. Try not to hit your head, Um, just things like that. So, just like useful things for next year like that's the thing that you'll have to actually do quite a lot. So I've put the explanation there so you can have a read through it. Um, Dabigatran is your only does act that has a reversal agent. None of the other ones do. That's the answer to that. Then the second one is an old man that's come in with, well, 61 year old man. It's coming to any. He's got painful cold, right foot. It came on suddenly. So it's an ischemic foot when you read that his radio pulse is 82 so he's not tachycardic, but it's not got pattern in it. So you're thinking maybe a f or something like that, Um, or like an arrhythmia. He's not sure he appears short of breath, which could be because he's in pain. Uh, he's got oxygen SATs of 98% on room er, which is pretty good. Um, there's nothing on the abdominal exam or the cardiac exam. Um, you can't feel the pulse in the foot. You can't see anything on the Doppler, and the E C G is fine, so you've got quite a lot of information there, but this is most likely to be a f so with a F patient's are at risk of because they're like the Atria Fibrillate rather than contract properly, you get like pulling of blood, gets a bit stagnant, can get a bit clotty clots can fire off and go and get stuck in other places. Lots of people worry about a stroke after af of strokes with a F. But like like ischemic ling's can also happen. So I've just gone through here and explain why it's not all of the other ones. So, um, DVT is an unlikely cause of your acute lower limb ischemia. Um, so it's not likely to really be a DVT unless you're like you're thrombus embolize is go through the venous circulation to the heart, goes through a patent foramen ovale and then ends up in the, um, arterial um in the arterial circulation. But the chance of that happening are pretty low. Um, you know, it's not going to be an abdominal aortic aneurysm. There was nothing on the examination. If it was ruptured, he definitely wouldn't have a heart rate of 82. He'd be very tacky, Kartik. He'd be hypertensive. He probably would not be conscious. Um, if it was an aorta, I like this section. It would be very painful. Um, the fact that it's got irregularly irregular pulse suggest that it's a F, and you've got this symbolic event, so, like an endless has fired off from somewhere in the heart. Um, and it's not going to be an M. I because the E. C G suggests that there wasn't really anything on it. There's no chest pain. It could be an end like a silent am I. But like that's not the most likely diagnosis. Most likely thing to have happened is a F um, fine. I appreciate I'm rattling through these, um, last one, um, so a 66 year old male comes for his ultrasound of his abdominal aortic aneurysm. So he came once last year, and it was measured to be 3.8 centimeters, so that therefore means he has to come back in a year's time. So he came back in a year's time. He's still a symptomatic, but it's grown by 1.1 centimeters, which means it's grown by more than one centimeter in one year, and it's above four centimeters, which means it qualifies him for surgical intervention. Okay, um, it's this one here, more than four centimeters. Um, more than one centimeter in one year. So hopefully those make sense. Hopefully, that was helpful. I'm sorry that I've run over a little bit. Um, I would really appreciate it if you could just scan this QR code and answer these four questions for feedback. It comes in really helpful. Um, and it's just good for me to know, um, what to do better next time. So I'd really appreciate it if you can fill that out for me. Um, I'll just leave it on the screen for a couple of seconds just for you to be able to scan. And then I will see if there are any other questions. Okay. Right. I'm gonna turn. Okay. Cool. And I don't think there are any other questions. I can't see anything coming up in the chat, so I'm going to take that as no questions. I think one question just come up. I can't actually see these. So could you read it out for me, please? Um, so one per thoracic aortic aneurysm. A thoracic aortic aneurysm. That is a good question and I was also thinking about this earlier today, so there's nothing like I was reading through the nice guidelines. So a thoracic aortic aneurysm isn't actually on the Sofia specification. Um, and then from my reading, it would basically be a referred referral to cardio thoracic because it would be like, um, like you'd have to open up the heart and, like, fix it that way. Um, I think if it's pretty bad, you probably would. But I didn't look into it in a lot of detail. Um, I just know that as soon as that things get quite bad within the thorax, you probably refer to cardiothoracic, but they're quite specific that it's just like aortic abdominal aortic aneurysm. Zootopia. So I wouldn't worry about that one too much. That's no cancer for you. And earlier on, Daniela asked, Why do you need duplex ultrasound and m R E t angio? Um, so I mean, it's kind of like a step wise thing. Um, whenever you're like investigating people, you'd probably do a, um you probably do an ultrasound first, and then you do an MRI and an MRI, and you obviously a duplex is only like like two dimensional. But with MRI, you can get three dimensional images. And also like, realistically, it takes a bit of time for people to get these MRI. So it's good to, like, kind of have both. So, in general ultrasounds done pretty quickly, usually same day stuff like that. So we'll do one and then you probably do another one. I think those are all the questions. Thank you so much for giving the tutorial. No worries. I've emailed you the slide so hopefully you can distribute those. And hopefully my email's on the slide. So if anyone has any questions, you're welcome to drop me an email and ask. Cool. Awesome. Thanks. You're welcome. Good luck with finals. Bye. Take care.