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306 Cards in this Set
- Front
- Back
Name the renal arteries in order from Aorta to the edge of the parenchyma.
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Main renal artery -> segmentals -> interlobars -> arcuates -> interlobulars
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A patient has a PE and a test is being performed to determine the source of the PE. Which test is it? CT, MR, Nuc Med, Duplex US
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Duplex US
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A patient has an above-the-knee amputation. What is the most likely cause of death in the next 5 years?
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Sepsis from gangrene
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You measure the celiac artery velocity pre-prandial. How does the velocity compare post-prandial?
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Should remain the same
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MCA: depth, direction, mean velocity, window
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3 - 6 cm; toward txr; 55 +/- 12 cm/s; transtemporal
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ACA: depth, direction, mean velocity, window
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6 - 8 cm; away from txr; 50 +/- 11 cm/s; transtemporal
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PCA: depth, direction, mean velocity, window
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6 - 7 cm; P1 = toward, P2 = away; 39 +/- 10 cm/s; transtemporal
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terminal ICA: depth, direction, mean velocity, window
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5.5 - 6.5 cm; bidirectional; 55 +/- 12 cm/s (per Rumwell) or 39 +/- 9 cm/s (per Daigle); transtemporal
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Ophthalmic: depth, direction, mean velocity, window
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4 - 6 cm; toward; 21 +/- 5 cm/s; transorbital
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ICA siphon: depth, direction, mean velocity, window
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6 - 8 cm; supraclinoid (C2) = away & 41 +/- 14, genu (C3) = bidirectional, parasellar (C4) = toward & 47 +/- 11; transorbital
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Vertebrals: depth, direction, mean velocity, window
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6 - 9 cm; away; 38 +/- 10 cm/s; transforamenal
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Basilar: depth, direction, mean velocity, window
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8 - 12 cm; away; 41 +/- 10 cm/s; transforamenal
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ICA: depth, direction, mean velocity, window
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3.5 - 7 cm; away; 37 +/- 9 cm/s; submandibular
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Name the artery that becomes the common femoral artery at the inguinal canal
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External iliac artery
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Name the artery that the superficial femoral artery becomes at the adductor canal.
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Popliteal artery
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The common femoral artery bifurcates into what two major arteries?
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Superficial femoral artery, Deep femoral artery (profunda femoris)
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A common collateral artery branching at the adductor canal is
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Genicular branches
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Of the trifurcation vessels branching from the popliteal artery the first one to take off is
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ATA
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The posterior tibial and the peroneal artery branch from the
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Tibioperoneal trunk
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The dorsalis pedis is a continuation of this artery
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ATA
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What artery may be palpated posterior to the medial malleolus?
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PTA
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What affect does diabetes mellitus have on the arterial wall?
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The walls become hardened (less compliant) and have a greater tendency toward atherosclerosis.(Medial calcinosis)
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Describe a mycotic aneurysm
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a localized dilation in the wall of a blood vessel caused by the growth of a fungus. It usually occurs as a complication of bacterial endocarditis.
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What makes a pseudoaneurysm different from an aneurysm?
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An aneurysm is a dilatation of all 3 layers of the arterial wall; a pseudoaneurysm is essentially a pulsating hematoma wherein a hole in the arterial wall permits blood to escape under pressure into an area contained by the adjacent tissue.
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What is the characteristic flow pattern in the neck of the pseudoaneurysm?
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To/Fro flow; at systole blood flows from the artery into the lumen of the pseudoaneurysm, at diastole blood flows from the pseudoaneurysm back to the artery.
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What is the characteristic flow pattern in the lumen of the pseudoaneurysm?
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Yin/Yang; represents a swirling of the blood leaked from the artery into the contained area of the pseudoaneurysm
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What is the potential risk of pseudoaneurysms?
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Rupture; if the pseudoaneurysm ruptures, then the leak from the artery is no longer contained and large amounts of blood could extravasate.
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List two methods of treating pseudoaneurysms
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Ultrasound guided manual compression, ultrasound guided thrombin injection
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Define compartment syndrome
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Swelling within the osteofascial compartments of the leg or arm cause intercompartmental pressures to increase to the point where they exceed capillary perfusion pressure, therby decreasing vascular perfusion and compromising nutritive blood flow to the tissue.
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What are the sonographic signs of compartment syndrome?
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Calf muscles may look misshapen, evidence of hematoma may be seen.
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How is compartment syndrome treated?
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Fasciotomy
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Describe coarctation of the aorta
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Congenital narrowing or stricture of the thoracic aorta that may affect the abdominal aorta as well. May have hypertension due to decreased kidney perfusion or manifestations of lower extremity ischemia.
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Identify the muscle/s involved in popliteal entrapment syndrome
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Medial head of the gastrocnemius muscle or fibrous bands
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Who is generally affected by popliteal artery entrapment syndrome?
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Young men
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What is the primary symptom of popliteal artery entrapment syndrome?
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Symptomatic arterial occlusion or intermittent claudication
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Define gangrene
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Tissue death caused by deficient or absent blood supply
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Define ischemic rest pain
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A more severe symptom of diminished blood flow to the most distal portion of the extremity; usually occurs when the limb is not in a dependent position and the patient’s blood pressure is decreased; symptoms occur in the forefoot, heel, and toes, but not in the calf
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The toe pressure threshold for predicting healing of the foot is
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> 30 mmHg.
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List the five P's of acute arterial disease
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Pain, Pallor, Pulselessness, Paresthesia, Paralysis.
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Define pallor
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Pale skin resulting from a deficient blood supply
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Define Paresthesia
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Tingling, numbness, or lack of feeling
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Define the pulse ratings
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0 = None, 1 = Weak, 2= Good, 3 = Strong, 4 = Bounding (Aneurysmal)
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Identify four areas of the lower extremities where pulse pressures may be evaluated
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Femoral artery, Popliteal artery, Dorsalis pedis, Posterior tibial arteries
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What is the formula for PI – pulsatility index?
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(Peak-to-Peak Frequency) / Mean Frequency
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What is the formula for AT -acceleration time?
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(Initial peak time) – (Time at onset of systole)
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What is the recommended cuff size for taking arterial pressures?
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1.2 X the diameter of the limb
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List the diagnostic criteria for segmental pressure exam interpretation.
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Normal: > 1.0
Single level disease: > 0.5 Multi-level disease: < 0.5 Rest pain: < 0.35 |
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What is the threshold for abnormal TBI -toe brachial index?
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< 0.6
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What is the typical size of a toe pressure cuff?
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2.5 – 3 cm cuff
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Describe the procedure for reactive hyperemia
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Alternate method to exercise for stressing the peripheral circulation. May be indicated when the patient cannot walk long enough. Thigh cuffs (19 X 40 cm) are inflated to Suprasystolic pressure levels (20 – 30 mmHg above the higher brachial blood pressure) and maintained for 3 – 5 minutes. This produces ischemia and ultimately vasodilation distal to the cuff. Upon release of cuff occlusion, the changes in ankle pressures are similar to those observed after exercise. There may be a transient pressure decrease in the range of 17% - 34% in normal limbs after reactive hyperemia.
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Define pneumoplethysmography
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Air, volume, or true Plethysmography. The more arterial blood flow present moving underneath the air-filled cuff bladder, the greater the analog waveform excursion. When there is a decrease in arterial flow underneath the cuff due to obstructive disease, the waveform changes appearance.
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Define Photoplethysmography
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Detects cutaneous blood flow and records pulsations rather than recording volume changes. Not true Plethysmography. Rapid changes in blood content of the skin are recorded as pulsatile waveforms with each heartbeat. Infrared light is sent into the underlying tissue with an LED, and the adjacent photodetector (photocell) receives the backscattered infrared light and measures this reflection of light. As light is directed into the skin, the tissue and the blood in the cutaneous vessels attenuates a portion of it. Provides qualitative not quantitative flow information.
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What pressure are the cuffs inflated to obtain pulse volume recordings?
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10 – 65 mmHg
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Describe “blue toe syndrome”
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May be caused by ulcerated &/or atherosclerotic lesions, emboli, the inflammatory process of arteritis (thrombosis), and some angiographic procedures resulting in lack of flow at distal arterial endpoints, resulting in a cyanotic toe.
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Describe the affect of a proximal stenosis on a distal stenosis
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Causes pressure and flow volume to decrease further than with a single stenosis. This could lead to an overestimation of vascular consequence of the distal stenosis and an underestimation of the effect of the proximal stenosis.
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What is the most common site of lower extremity aneurysms?
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Popliteal artery
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What muscle lies lateral to the external iliac artery?
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Psoas major muscle (or iliopsoas)
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Define claudication
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Pain in muscles occurring during exercise but subsiding with rest. Discomfort is usually predictable, occurring with the same amount of work and disappearing within minutes of activity cessation. Results from inadequate blood supply to the exercising muscle, which may be caused by arterial spasm, atherosclerosis, arteriosclerosis, or an occlusion.
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Describe Buerger's disease including who it primarily affects
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The most common form of arteritis. Also known as thromboangiitis obliterans. Associated with heavy cigarette smoking and men < 40. Patchy areas of ulceration or gangrene.
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Describe an AVF – arterial venous fistula
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Congenital or traumatic abnormal connection between high-pressure arterial system & low-pressure venous system; causes marked anatomic & hemodynamic changes
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What is the formula for calculating an ABI?
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(Ankle systolic pressure) / (higher of the two brachial systolic pressures)
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What is the pressure gradient considered abnormal for segmental pressure exams of the lower extremities?
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> 30 mmHg between two consecutive levels
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Describe atherectomy
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An alternative to percutaneous transluminal angioplasty that cuts through or pulverizes the plaque with a rotational device at the end of the catheter.
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Describe endarterectomy
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The surgical removal of atherosclerotic material, and usually a portion of the intimal lining, from the arterial lumen.
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Describe angioplasty
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Used to dilate the precise segment of a vessel that contains a focal atherosclerotic lesion using a balloon-tipped catheter to push plaque against the walls of the vessel under fluoroscopic guidance.
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Describe the difference between the vasospastic disorders, primary Raynaud’s Syndrome (Raynaud’s disease) and secondary Raynaud’s Syndrome (Raynaud’s phenomenon):
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Vasospastic disorders occur due to a severe narrowing of the arterial lumen, usually without occlusion. Primary Raynaud’s is intermittent digital ischemia caused by digital arterial spasm. It may be hereditary, is usually bilateral, and the patient commonly presents with a long-term history of symptoms without progression or evidence of underlying cause. Secondary Raynaud’s is normal vasoconstrictive responses of the arterioles superimposed on a fixed arterial obstruction. Ischemia is constantly present. May be the first manifestation of a collagen disorder, Buerger’s disease, anatomic abnormality, or other underlying cause.
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Identify the four structures the subclavian artery, subclavian vein, brachial plexus pass through that will sometimes cause an impingement known as thoracic outlet syndrome
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Cervical rib, costoclavicular, anterior scalene muscle, middle scalene muscle
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Describe Adson maneuver
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Exaggerated military stance (shoulders back) with head turned sharply toward and then away from the arm being tested.
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Describe the costoclavicular maneuver
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Exaggerated military stance (shoulder blades pinched); depressing and retracting the shoulders as if standing at attention, extending the humerus and abducting it 30°, and hyperextending the neck and head.
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Describe the hyperabduction maneuver
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Patient’s arm is moved passively through a 180° semi-circle through the frontal plane to overhead
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T/F: When using Velcro to secure the PPG transducer, it should be wrapped as tightly as possible
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False
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Normal finger pressures should be ______ of the normal ipsilateral brachial systolic pressure.
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> 80 - 90%
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A normal finger/brachial index is
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0.8 - 0.9
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A pressure gradient of ____ between fingers is indicative of disease
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15 mmHg
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List three common symptoms of thoracic outlet syndrome
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Numbness or tingling of arm, pain or aching of shoulder and forearm, exercise and upward arm positions can increase discomfort and exacerbate symptoms.
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TOS is difficult to diagnose with ultrasound because 95% of the time the pain is
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of neurogenic origin
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The PPG waveform significantly increases/decreases (circle one) in an abnormal response to a maneuver in testing for TOS.
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Decreases
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As many as ____ of individuals demonstrate arterial compression during TOS maneuvers.
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25% to 30%
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A peaked pulse PVR waveform is indicative of
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Primary or secondary Raynaud’s
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The____ artery supplies blood to the superficial palmar arch.
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ulnar artery
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The ____ artery supplies blood to the deep palmar arch
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radial artery
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____ branches connect the deep palmar arch to the superficial palmar arch.
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Radial and ulnar
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Venous reflux testing using PPG is set in AC / DC (circle one) mode.
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DC
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T/F: The PPG sensor should be placed directly over an artery in testing for venous reflux.
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F
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Describe the patient position for venous reflux testing using PPG sensors.
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The patient is seated with legs dangling (non-weight bearing)
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The normal refill time in venous reflux testing is
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>/= 20 seconds
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An abnormal refill time before and after the application of a tourniquet suggests deep/superficial (circle one) venous insufficiency.
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Deep
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If the refill time returns to normal after the application of a tourniquet suggests deep/superficial (circle one) venous insufficiency.
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Superficial
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Identify two causes of erectile dysfunction that may be diagnosed by either duplex scanning or physiologic testing.
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Cavernosal venous leak, arterial insufficiency
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The dense fibrous sheath that encapsulates the sinusoidal tissue of the corpora cavernosa is called
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tunica albuginea
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T/F: The PPG sensor should be placed directly over an artery in testing for venous reflux.
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F
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Describe the patient position for venous reflux testing using PPG sensors.
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The patient is seated with legs dangling (non-weight bearing)
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The corpus spongiosum is located on the dorsal/ventral (circle one) side of the penis.
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Ventral
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The normal refill time in venous reflux testing is
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>/= 20 seconds
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In what compartment is the urethra located?
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Corpora spongiosum
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Describe the location of the helicine arteries in the penis.
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Corpus cavernosa.
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An abnormal refill time before and after the application of a tourniquet suggests deep/superficial (circle one) venous insufficiency.
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Deep
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If the refill time returns to normal after the application of a tourniquet suggests deep/superficial (circle one) venous insufficiency.
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Superficial
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Identify two causes of erectile dysfunction that may be diagnosed by either duplex scanning or physiologic testing.
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Cavernosal venous leak, arterial insufficiency
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The dense fibrous sheath that encapsulates the sinusoidal tissue of the corpora cavernosa is called
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tunica albuginea
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The corpus spongiosum is located on the dorsal/ventral (circle one) side of the penis.
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Ventral
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In what compartment is the urethra located?
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Corpora spongiosum
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Describe the location of the helicine arteries in the penis.
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Corpus cavernosa.
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Describe venous leak (venous incompetence) in regard to erectile dysfunction
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An insufficient veno-occlusive mechanism
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List two drugs commonly used to induce an erection for Doppler evaluation
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Papaverine, prostaglandin E
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Normal velocities of the cavernosal artreries are greater than
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30 cm/sec
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Normal blood flow at full tumescence of the cavernosal arteries is high/low (circle one) resistive.
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High
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A discrepancy in maximum velocities of the cavernosal arteries ____ between left and right indicates some degree of arterial insufficiency
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greater than 10 cm/sec
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A Doppler finding suggestive of penile venous incompetence is flow in the
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Deep dorsal vein.
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High diastolic flow ____ in the cavernosal artery may indicate a venous leak through ____
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> 5 cm/sec ; Deep dorsal vein
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Describe an aorto-aortic stent graft
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Tubular, single body device that fixes to athe aortic wall proximally, and to the aneurysm sac distally
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Describe an aorto-iliac stent graft, with femoro-femoral graft:
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A graft between the aorta and one of the iliac arteries with another graft between the two femoral arteries; bypasses the contralateral iliac artery.
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Describe an aorto-femoral stent graft with femoro-femoral graft:
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A graft between the aorta and a femoral artery with another graft between the two femoral arteries
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A patient with an aorto-femoral stent graft on the right and femoro-femoral graft. How blood get to the pelvic area?
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Collateral blood flow
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Define allograft
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Transplant of tissues, organs, or cells between two members of the same species but with different genotypes.
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Typically a renal allograft is placed (retroperitoneal, extraperitoneal). Circle one.
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Extraperitoneal
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Describe three ways the renal allograft artery is attached.
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a. End-to-side with external iliac artery
b. End-to-end with the internal iliac artery c. Donor Aortic patch to side of external iliac artery |
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List the three most important manifestations of renal allograft failure.
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a. Increased renal transplant size
b. Increased cortical echogenicity c. Hypoechoic regions in the parenchyma {Prominent Pyramids} |
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List three waveform changes associated with renal allograft failure
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a. High-resistive; pulsatile
b. Spectral broadening c. Tardus Parvus waveform in the parenchyma |
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Duplex is used post-op of a hepatic allograft to document patency of six vessels. What are they?
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Portal vein, splenic vein, SMA, hepatic veins, IVC, hepatic artery
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Identify three sonographic signs of hepatic allograft failure
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a. High-resistive or no flow or tardus parvus in the hepatic artery (stenosis/occlusion); collateral formation at porta hepatis; areas of infarct
b. Portal vein thrombosis c. Hepatic vein stenosis; absence of flow or monophasic waveform |
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The Soleal veins drain into the
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Posterior tibial veins and the Peroneal veins.
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The longest vein in the body is the
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Great saphenous vein.
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Veins that connect the superficial veins to the deep veins are called
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perforators
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Blood flow in perforating veins flow from
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superficial veins to deep veins
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The communication between the posterior arch vein and the posterior tibial vein is through the
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Cockett’s perforators
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What is the Soleal sinus?
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A dilated channel of the lower calf muscles that allows venous blood to accumulate and then drain into the PTVs and Per vv.
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Blood flows from the soleal veins to the
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Posterior tibial or Peroneal veins
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What is the vein that is formed by the confluence of the axillary and cephalic veins?
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Subclavian vein
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The renal veins drain into the
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IVC
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What is the function of a venous valve?
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To keep blood flowing in only one direction
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List eight veins that typically do not have valves.
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(1) Soleal sinuses, (2) External iliac, (3) Internal iliac, (4) Common iliac, (5) IVC, (6) Subclavian, (7) Innominates, (8) SVC.
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What is transmural pressure?
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Difference between pressures within (intraluminal) & outside (interstitial) the veins; determines the cross-sectional shape of veins.
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Increased transmural pressure will make the vein appear more ____ in cross-section.
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circular and large
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The ____ veins empty during the relaxation phase.
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superficial
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Normal blood flow in the perforating veins is: (circle one)
a. superficial to deep b. deep to superficial |
a
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Inspiration increases or decreases (circle one) pressure in the abdominal cavity and increases or decreases (circle one) in the thoracic cavity
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increases; decreases
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List four of the most common clinical findings of DVT
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Swelling, Pain, Redness (erythema), Warmth.
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According to Wells scoring for the probability of DVT, a score of ____ indicates a high probability.
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> 3
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List five clinical signs of chronic venous insufficiency
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Swelling, Heaviness, Discoloration, Ulcerations, Varicosities.
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List the three components of Virchow's triad
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Trauma (endothelial damage), Venous stasis, Hypercoagulability.
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List one example of each of the three states of Virchow’s triad
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Intrinsic trauma, Pregnancy, Cancer.
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Describe Paget-Schroetter syndrome:
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Thrombosis of the subclavian or axillary vein secondary to intense, repetitive activity. Aka: stress or effort thrombosis; the venous component of TOS. Frequently associated with upper extremity repetitive motions.
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Describe May-Thurner syndrome
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Compression of left common iliac vein by right common iliac artery as artery crosses over it. In some cases artery causes enough compression to thicken vein wall and alter flow to the point of thrombosis.
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Describe a pulmonary embolism (PE):
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Part or all of a thrombus breaks loose and travels into the pulmonary circulation.
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What contributes to brawny discoloration of the skin?
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Fluid, RBCs, and fibrinogen leak into the surround tissue as a result of increased venous pressure. The breakdown of RBCs creates hemosiderin deposits.
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List the signs of post thrombotic syndrome
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Chronic swelling, brawny discoloration, and ulcer formation in the gaiter zone.
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Describe Klippel-Trenaunay syndrome
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Hypoplastic or absent deep veins (i.e., absent iliacs with varicosities of superficial system resulting in an enlarged limb.
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What is the term that is used to describe blood flow away from the liver?
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Hepatofugal
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Describe the difference between primary and secondary varicose veins.
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1° = result of congenital absence of > 1 valve; unrelated to DVT. 2° = caused by obstructive conditions of deep system, e.g., previous DVT, pregnancy, or obesity.
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Describe lipodermatosclerosis
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Thickening and hardening of the skin; can be found in patients with CVI. High venous pressure allows RBCs and fluid to leak into tissue, leading to chronic inflammation. When the skin and fat under the skin are inflamed for years, tissue becomes hard. Over time the tissue becomes depressed, changing the contour of the ankle are in a manner referred to as “bottle-neck deficiency”.
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Describe phlegmasia alba dolens including the cause
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A limb-threatening condition resulting from arterial spasms that occur 2° to extensive, acute iliofemoral vein thrombosis. Limb is very swollen, pale (whiteness / pallor), and painful.
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Describe phlegmasia cerulean dolens including the cause:
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A limb-threatening complication of acute iliofemoral vein thrombosis. Severely reduced venous outflow causes a marked reduction in arterial inflow. Tissue hypoxia can develop, leading to venous gangrene. Limb is very swollen, dark blue (cyanotic), and painful.
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Describe an arterial ulcer
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Little bleeding; located on toes or bony prominences; shiny skin; thickened toe nails; regular shape; severe pain
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Describe a venous ulcer
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Mild to severe pain; shallow irregular shape; located in medial gaitor area; oozes fluid; brawny discoloration; irregular shape
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Describe neurogenic ulcers
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Also known as diabetic ulcers, are ulcers that occur most commonly on the bottom of the foot. People with diabetes are predisposed to peripheral neuropathy, which involves a decreased or total lack of sensation in the feet. Feet are naturally stressed from walking, and someone who has decreased sensation will not necessarily feel that they have an area of skin breakdown occurring. Coupled with this lack or absence of sensation is a decrease in circulation to the feet as well. Wounds that do not get proper blood flow are not only slower to heal but also at an increased risk for infection. A small cut, scrape, or irritated area in a diabetic can turn into an ulcer for these reasons. It is common for these types of ulcers to keep coming back in diabetics.
A neurogenic ulcer begins with thickening and a callus on an area of pressure, followed by skin breakdown (an ulcer). |
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Discuss and differentiate the different types of edema.
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Pitting edema = accumulation of fluid in the subcutaneous tissue. When manual pressure is applied on the tissue, some fluid is displaced causing a depression in the skin surface. May be 2° to fluid retention, an electrolyte imbalance, renal dysfunction, CHF or other causes of elevated venous pressure. Non-pitting edema = tissue is so engorged with fluid that it cannot be displaced with manual pressure. Lymphedema is a non-pitting edema resulting from an obstruction in the lymphatic system.
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Define / describe impedance plethysmography IPG
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Can detect thrombi in iliac, femoral, and popliteal veins. As blood volume in calf increases in response to cuff, resistance decreases and thus current to the sensors increases. Once cuff is released, resistance increases and current decreases. The blood in the calf should go from maximum venous capacitance back to baseline within 3 seconds.
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Describe strain gauge plethysmography SPG
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Can detect obstruction in large veins above the knee (e.g., femoral). A Hg-in-Silastic strain gauge measures changes in leg circumference as blood fills the leg 2° to cuff obstruction. Once the maximum venous capacitance is reached and the cuff is released, the circumference should return to baseline within 3 seconds.
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What is the major difference between IPG and SPG as far as what is being measured in the calf?
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In IPG the blood volume is being measured via increased resistance. In SPG, the leg circumference is being measured as it increases when filling.
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In cases of DVT there is reduced maximum venous capacitance (MVC) because?
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Blood volume in limb can’t increase from baseline, since limb can’t be properly emptied before test due to obstruction.
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In cases of DVT there is reduced maximum venous outflow (MVO) because?
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Once cuff is released, blood can’t efficiently empty from leg due to obstruction.
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Venous testing requires the use of [direct or alternating] (circle one) current.
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Direct
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Venous outflow is determined by how much volume decreases in
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3 seconds
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Describe photoplethysmography (PPG).
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Documents capillary blood volume and evaluates the presence and severity of venous insufficiency. Determines changes in blood content of skin by a photosensor that transmits light into the subcutaneous tissues. Since blood attenuates light in proportion to its content in the tissue, the difference between the transmitted and reflected signal can be converted into a waveform.
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The PPG sensor should be placed directly over an artery in testing for venous reflux. True/False
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False
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Describe the patient position for venous reflux testing using PPG sensors
|
The patient is seated with legs dangling (non-weight bearing).
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Normal refill time for VRT testing is
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> 20 seconds.
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If the VRT test is abnormal without a tourniquet and normal with a tourniquet applied above the knee this indicates
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reflux in the Great saphenous vein
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If the VRT test is abnormal with and without a tourniquet this indicates
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insufficiency of the deep system
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Describe the principle of air plethysmography
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Measures volume changes in the extremity and evaluates the efficiency of the venous calf pump. Also can determine the presence or absence of venous insufficiency and quantify venous reflux. This is accomplished by measuring, via pressure transducers, the venous volume and filling time as the patient stands from supine, does 1 toe-up (ejection volume), and then does 10 to-ups (residual volume).
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Describe the limitations of CW Doppler in evaluating for DVT
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Difficult to differentiate if abnormal flow is due to DVT or extrinsic compression; paired deep veins in calf make diagnosis of isolated calf-vein thrombosis difficult; PAD decreases venous filling; COPD elevates central venous pressure; improper angle / pressure alters interpretation; can’t differentiate partial from total thrombosis; collateral development may give false-negative; bifid system may give false-negative; requires very experienced sonographer.
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The patient position for lower extremity venous Duplex examinations is
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reversed Trendelenburg with patient turned toward the symptomatic side with the hip externally rotated and the hip and knee flexed slightly
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Performing Duplex Doppler imaging of a lower extremity vein, in what view should the Doppler signal be obtained? Transverse or Longitudinal (circle one)
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Long
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List four things the Doppler signals are used to evaluate in lower extremity venous Doppler examinations
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Spontaneity, phasicity, augmentation with distal compression, augmentation with proximal release
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Baker's cysts are usually found (medial/lateral)
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Medial
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Describe the development of DVT and the location where it most commonly develops
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Intraluminal thrombi, predominately composed of RBCs trapped in a fibrin web, frequently originate at the cusps of the venous valves or in the soleal sinuses due to stagnation. As the clot propagates, flow becomes restricted, venous pressure increases, the vein walls stretch, and the venous valves can be damaged.
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Describe the process of hemosiderin deposition
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Fluid, RBCs, and fibrinogen leak into surrounding tissue due to increased venous pressure. The breakdown of RBCs creates hemosiderin deposits that cause brawny discoloration.
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Describe primary varicose veins
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Varicose veins in the absence of coexisting deep vein thrombosis
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Describe secondary varicose veins
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Sequela to deep vein thrombosis
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Describe recurrent varicose veins
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Varicose veins that reappear after venous ablation therapy
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List three common symptoms of pulmonary embolism
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Shortness of breath / difficulty breathing, chest pains, coughing (esp. with blood)
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Define venous insufficiency
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A condition in which the veins have problems sending blood from the legs back to the heart. Caused by problems in one or more deep leg veins. Normally, valves keep blood flowing back to heart so it doesn’t collect in one place. But if valves are either damaged or missing, veins remain filled with blood, especially when standing. May also be caused by a blockage in a vein from a clot (DVT). CVI is a long-term condition that occurs because of partial vein blockage or blood leakage around the vein valves
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List four clinical signs/symptoms of venous insufficiency
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Edema (pitting), Dilated veins, Leg pain, Skin changes in ankle area (Coloration / Thickening)
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Define stasis dermatitis
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Inflammatory skin condition that develops 2° to fluid build-up, or blood pooling (stasis), just under the skin due to problematic circulation. The extra fluid that builds up in the body makes it hard for blood to feed cells & get rid of waste products. Tissue becomes poorly nourished and fragile. Common at the ankles due to less supportive tissue. The rash associated with stasis dermatitis can have the following characteristics: Thin, inflamed, tissue-like skin; Itching; Tingling; hemosiderin deposits; dry, scaly patches of skin; hyperpigmentation; thickening of skin; slow to heal venous ulcers.
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Describe how collateral flow will affect the Doppler signal
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Continuous flow seen in presence of acute DVT or when collateral flow is not adequate. May show bi-directional flow.
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List four characteristics of acute thrombus
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Incomplete compressibility of veins, low-level echoes within lumen, vessel is dilated compared to accompanying artery, thrombus is poorly attached to wall & may have a spongy texture
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List four characteristics of chronic thrombus
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More echogenic, visible collateralization or recanalization, synechia, vessel is not dilated
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Describe the nuclear medicine study called VQ (ventilation quotient) scan
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Screening test for detection of perfusion defects of lungs, most commonly attributed to a PE. Radioactive contrast medium injected into arm & images of lung perfusion taken from various angles. Other disorders can also cause perfusion defects.
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The basilic vein lies medial or lateral to the brachial veins? (Circle one)
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Medial
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Are the following superficial or deep: Basilic; Brachial; Axillary; Cephalic; Subclavian; Innominate; Radial; Ulnar; Medial cubital
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S; D; D; S; D; D; D; D; S
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What two things should be done to evaluate the subclavian vein in place of compression by the transducer?
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Have patient take in quick deep breath through pursed lips; augment with distal compression (may be reduce or not evident)
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What is the typical flow characteristic of the subclavian vein?
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Pulsatile due to proximity to the heart; augmentation with distal compression may normally be reduced or not evident.
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The outflow vein of a patent dialysis access graft will exhibit the following 5 changes
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Increased flow velocity and volume flow, pulsatile flow, no response to distal compression, incompressible vessel, collateral channels evident
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How would you describe the walls of the portal vein?
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Hyperechoic
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How would you describe the waveform appearance of the normal portal vein?
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Minimally phasic, almost continuous; in the adult patient, flow is essentially not affected by normal respiration.
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What is the normal response to deep inspiration for the abdominal and pelvic veins?
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They should dilate
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What is the appearance of Rouleau flow?
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RBCs look like rolls of coins; very sluggish flow; B-mode appearance = heterogeneous material moving with respirations & augmentation; suggests slow flow due to proximal obstruction, increased proximal venous pressure, or other processes (increase in plasma immunoglobulin).
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Describe portal hypertension
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Increased BP in portal vein from increased resistance to blood flow which can result from pathology of portal vein, small intrahepatic portal vein radicles, hepatic parenchyma, or hepatic veins. Pathology varies and includes cirrhosis, cancer, pancreatitis, thrombosis, & trauma; portosystemic venous collaterals may develop; can result in hepatofugal flow.
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Describe Budd-Chiari syndrome
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Results from hepatic vein occlusion. Abnormal clinical findings include hepatomegaly, abdominal pain, sudden onset of ascites. Causes are many and vary with regard to the primary site of obstruction (hepatic vein level, sinusoids, or IVC).
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What does a positive D-dimer test indicate?
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Lysis (breakdown) of thrombus.
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Describe and compare ascending and descending venography.
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Ascending = used to evaluate acute DVT, congenital venous disease, &/or anomalies, and in the evaluation of chronic venous changes; contrast agent is injected into a vein on the dorsum of the foot. Descending = used primarily to detect and quantify reversed flow from incompetent venous valves; contrast agent is injected into CFV.
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Name two contraindications to venography
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Severe allergies to iodine, severe peripheral vascular occlusive disease.
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Describe the typical treatment for acute DVT
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Medical therapy: 10,000 units of heparin followed by continuous IV infusion for 5 – 10 days. Surgical and endovascular therapy: IVC filters.
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Name two types of vena cava filters
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Greenfield, bird’s nest filter
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Name three methods of treating venous ulcers
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Medicated wrap/dressing (e.g., Unna boot, Profore dressings), Hyperbaric oxygen therapy, Ligation of incompetent perforators.
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Name three methods of treating varicose veins
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Saphenous vein removal or phlebectomy (local excision of varicosities), Sclerotherapy, Venous ablation.
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What percentage of blood in the common carotid artery flows into the internal carotid artery?
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70-80%
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What is the first major branch of the internal carotid artery?
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Ophthalmic artery
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What are the two major terminal branches of the internal carotid artery?
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Middle cerebral artery, anterior cerebral artery
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What is the artery that takes blood to the brain, eyes, forehead, and nose?
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Internal carotid artery
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Is the internal carotid artery high resistive or low resistive? (circle correct answer)
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Low resistive
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What is the first branch of the external carotid artery?
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Superior thyroid artery
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What is the best way to differentiate between the internal and external carotid artery?
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The extracranial portion of the external carotid artery has branches and the internal does not.
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Often the vertebral arteries are asymmetrical in size (diameter). Which side is usually the larger diameter?
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Left
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What artery supplies blood to the posterior structures of the cranial cavity?
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Basilar
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What is the most important collateral structure in the cerebrovascular system?
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Circle of Willis
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The branches of this artery join with the supraorbital artery to form a collateral pathway
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Superficial temporal artery
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The nasal artery is a branch of the ____________, which becomes the _____________ and connects to the external carotid artery by way of the _______________.
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Frontal artery, angular artery, facial artery
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Define the term listed below including type of cells and function: Intimal layer
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single layer of endothelial cells with a base membrane and connective tissue.
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Define the term listed below including type of cells and function: Medial layer
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thick layer of smooth muscles and collagenous fiber that is usually arranged in a circular fashion
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Define the term listed below including type of cells and function: Adventitia layer
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thin fibrous layer of connective tissue and some smooth muscle fibers. This layer contains the vasa vasorum
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Define the term listed below including type of cells and function: Vasovasorum
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supplies blood to the adventitia layer
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The anterior circulation of the brain is fed by what two major branches of the circle of Willis?
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Anterior cerebral artery, middle cerebral artery
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The posterior circulation of the brain is fed by what major branch of the circle of Willis?
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Posterior cerebral artery
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Define Transient ischemic attack TIA
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symptoms last from a few minutes to few hours but resolve by 24 hours.
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Define Reversal ischemic neurological deficit RIND
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symptoms lasts longer than a TIA, but resolve in time.
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Define Stroke-CVA
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permanent neurologic deficits
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Define Vertebrobasilar insufficiency VBI
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causes bilateral symptoms of visual disturbance or paresthesia, and/ or vertigo, ataxia, drop attacks
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What type of stroke that is considered stable. Acute stroke, stroke in evolution, completed stroke. (circle one)
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Completed stroke
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Identify four risk factors associated with cerebrovascular disease
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Diabetes mellitus, hypertension, smoking, hyperlipidemia
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Define Ataxia
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defective muscular coordination especially that manifested when voluntary muscular movements are attempted.
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Define Syncope
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a brief loss of consciousness caused by reduction in cerebral blood flow
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Define Diplopia
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two images of an object seen at the same time
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Define Aphasia
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impairment of speech due to cerebral dysfunction
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Define Dysphasia
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lack of coordination of speech and failure to arrange words in an understandable way
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Define Dysphagia
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difficulty swallowing
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Define Amaurosis fugax
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temporary blindness (partial or total) because of transient ischemia of the retinal arteries.
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Define Bruit
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auscultory sound produced by turbulent or disturbed blood flow
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Define Dysarthria
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a speech disorder in which the pronunciation is unclear although linguistic and meaning are normal.
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Define Hemianopia
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blindness in one-half of the visual field, one or both eyes
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Define Hemiparesis
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muscular weakness affecting one side of the body
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Define Hemiplegia
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paralysis of one side of the body
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Define Monocular
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pertaining to one eye
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Define Paraplegia
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paralysis of the lower extremities, may include bowel and bladder.
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Identify the layer(s) that make up the capillaries
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Intimal layer only
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Arterial velocities of very young patients are usually higher or lower (circle one) than elderly patients
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Higher
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What is the most common type of stroke? Ischemic or hemorrhagic (circle one)
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ischemic
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The biggest risk factor for stroke is
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hypertension
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Describe neointimal hyperplasia
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Vascular smooth muscle cells accumulate in the intima and secrete matrix proteins. The migration of these cells from one tissue compartment to another followed by proliferation in the intima are required for intimal thickening. May cause restenosis
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Define atherosclerosis
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Disease of the arterial intima characterized by intimal proliferation (hyperplasia), deposition of fatty substances and luminal reduction
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Define Stenosis
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narrowing usually caused by atherosclerosis
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Define Fatty streak
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thin layer of lipid material on intimal layer
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Identify each symptom as either an indication for VB vertebro-basilar disease or CAR for Carotid artery system disease.
Ataxia; Diplopia; Aphasia; Syncope; Dysphasia; Dysphagia; Amaurosis fugax; Dysarthria; Hemianopia; Hemiparesis; Hemiplegia; Monocular |
Ataxia, VB; Diplopia, VB; Aphasia, CAR; Syncope, VB; Dysphasia, CAR; Dysphagia, VB; Amaurosis fugax, CAR; Dysarthria, CAR/VB; Hemianopia, CAR; Hemiparesis, CAR; Hemiplegia, CAR; Monocular, CAR.
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Define Fibrous plaque
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accumulation of lipids that is covered by more lipid material, collagen, and elastic fiber deposits.
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Define Complicated plaque
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fibrous plaque that contains fibrous tissue, more collagen, calcium, and cellular debris.
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Define Ulcerative lesion
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there is a break in the fibrous cap allowing blood to flow into the ulcer creating a place for thrombus to form and debris to form an emboli.
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Define Intraplaque hemorrhage
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sonolucent area within the plaque. This type of plaque is at a higher risk of rupture.
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Define Thrombosis
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coagulated blood held together with fibrin material
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A common sonographic sign of temporal arteritis is
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Homogeneously circumferentially thickened artery wall
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What is the location of a carotid body tumor?
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Between the internal and external carotid arteries
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Carotid body tumors are vascular or nonvascular (circle one) masses?
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Vascular
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What is the artery that usually supplies blood to a carotid body tumor?
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External carotid artery
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Define carotid dissection
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Defines the entry of blood into the wall of the artery separating the layers of the wall and creating a false lumen through which blood flows
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Fibromuscular dysplasia affects primarily what size of arteries? Which Sex? What age group?
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Medium, women, 25 – 50 year olds
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What condition/disease is associated with the “string of pearls” sign?
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Fibromuscular dysplasia
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What is at risk for development 6 to 24 months after an endarterectomy, graft, or stent procedure?
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Hyperplasia
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List three complications of plaque ulceration
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Emboli, thrombus, intraplaque hemorrhage
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Radiography uses what type of waves?
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X-rays
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Magnetic Resonance uses what type of waves?
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Radio waves
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Nuclear Medicine uses what type of waves?
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Gamma Rays
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A bruit is usually no longer heard with stenosis greater than
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90%
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What is the difference in appearance between a waveform obtained with a CW Doppler transducer and a waveform obtained with a PW Doppler transducer?
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There is not an apparent frequency window with CW Doppler waveform.
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Describe spectral broadening
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Loss of a frequency window obtained with a PW Doppler transducer demonstrating multiple frequencies / velocities. Turbulence
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Describe the waveform characteristics seen distal to a tight stenosis
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Dampened flow – decreased velocities, rounded waveforms, turbulence, higher diastolic flow.
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What are some methods to differentiate between a tight stenosis or an occlusion
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Increased the PRF to check for extremely high velocities, decrease the PRF to check for very low velocities for color and PW Doppler, use power Doppler, B-Flow if available, or dynamic flow if available.
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Describe the expected waveform appearance in an CCA when there is an ipsilateral ICA occlusion
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Loss of diastolic flow or very high resistive
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In general an unusually high resistant waveform means stenosis __________ and a tardis parvis appearing waveform means a stenosis ___________
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Distal, proximal
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Diminished flow in bilateral carotid arteries indicate
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Low cardiac output
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Diminished flow unilaterally indicate
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Proximal ipsilateral disease, proximal CCA or innominate
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A young person has elevated velocities, the reason for this might be
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Increased cardiac output
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Reversed diastolic flow bilaterally may be due to
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Aortic regurgitation or insufficiency
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What vessels may demonstrate compensatory flow in presence of an ICA occlusion.
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ECA, contralateral ICA, vertebrals (either side)
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A totally occluded CCA will cause which ipsilateral artery to have reversed flow?
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External carotid artery
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Define crosstalk as it applies to a spectral Doppler waveform
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Mirror imaging of the spectral waveform caused by strong reflectors or too much PW gain
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Intraoperative duplex monitoring can detect
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Stricture of the suture line, intimal flaps, areas of platelet aggregation, or residual plaque.
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Name three cerebral arteries seen through the transtemporal window , state the corresponding flow direction and insonation depth.
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MCA , toward, 30 - 60mm
ACA, away, 60 – 80 mm PCA, P1, toward, 60 – 70 PCA, P2, away, 60 – 70 ICAt, bidirectional, 55-65 |
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Name the window used to insonate the intradural vertebral artery
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Suboccipital, or transforamenal – same place, different name
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State the flow direction and the reference depth of the intradural vertebral artery.
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Away, 60 – 90mm
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Name the window used to insonate the ophthalmic artery
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Transorbital
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State the flow direction and the reference depth of the ophthalmic artery
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Toward, 40 – 60mm
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Name the cerebral artery with the highest expected velocity
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MCA
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While looking for vasospasm intracranially the MCA is serially evaluated for flow velocities. What are the normal velocities? ___________ What is the normal hemispheric ratio? __________.
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<120 cm/sec, <3
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Identify two conditions monitored using TCD intraoperatively
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Significant decrease in MCA flow velocities during cross-clamping, signals from microemboli.
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The angle of the Doppler beam to the vessel in handheld TCD is assumed to be ____________ degrees
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0
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Name three possible locations where a stenosis may be found causing a subclavian steal
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Lt subclavian artery, Rt subclavian artery, Innominate artery
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What is the difference in bilateral brachial blood pressures to cause suspicion of a subclavian steal?
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15 – 20 mmHg
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A subclavian steal is suspected on the side of the higher, lower (circle one) pressure.
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lower
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What is Milroy's disease?
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Hereditary lymphedema
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How long does recanalization of a DVT take?
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3 - 6 months
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What is Homan's sign?
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pain with dorsiflexion
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What is Neuhoff's sign?
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Pain 6 - 7" above Achilles tendon with palpitation of PTA
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What is Treuseu's sign?
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Clots forming in relation to hypercoagulability brought on by certain cancers
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What is lymphedema praecox?
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Meige's lymphedema - a type of hereditary lymphedema
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How long does it take for a DVT to organize & begin to adhere?
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6 - 12 hours
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On what basis is a diagnosis of superficial thrombophlebitis made?
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Physical exam (palpable cord, red, swollen)
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