Unknown

1
Unknown 131
2

• A 56 year old woman is evaluated for 1 year of
  lower extremity swelling and pigment changes.
  The swelling was initially transient, improving
  in the morning, but over the last few months, it
  is constant. She is in good health, and takes no
  medications. She states she occasionally gets
  short of breath if she need to go up two flights
  of stairs, but attributes it to the fact that she
  is not physically active.
• There is no history of chest pain, orthopnea, or
  thromboembolism.

3

• Physical exam is notable for normal vital signs,
  no elevation of JVP, and a normal cardiac and
  pulmonary exam. There is localized edema and
  darkening of the skin over the ankles
  bilaterally.
• Laboratory studies
• Hemoglobin 13.7 g/dL
• Leukocyte count 6,500/µL
• Platelet count 310,000/µL
• AST 23 IU/L
• ALT 26 IU/L
• Total protein 6.6 g/dL
• Albumin 3.9 g/dL
• Sodium 140 mEq/L
• Creatinine 0.9 mg/dL
• Glucose 85 mg/dL
• Urinalysis normal

4

• Which of the following physical exam findings is
  most likely to support the suspected diagnosis ?
• A) Absent pedal pulses bilaterally
• B) A 40-mm Hg difference in arterial pressure
  between a brachial sphygmomanometer and a femoral
  sphygmomanometer
• C) Loud bruits over the femoral arteries
• D) Rapid filling of the saphenous veins from
  above after going from trendelenberg to a
  standing position
• E) Tortuous, dilated veins around the umbilicus
  and a fluid wave

5

• Which of the following physical exam findings is
  most likely to support the suspected diagnosis ?
• A) Absent pedal pulses bilaterally
• B) A 40-mm Hg difference in arterial pressure
  between a brachial sphygmomanometer and a femoral
  sphygmomanometer
• C) Loud bruits over the femoral arteries
• D) Rapid filling of the saphenous veins from
  above after going from trendelenberg to a
  standing position
• E) Tortuous, dilated veins around the umbilicus
  and a fluid wave

6
Chronic venous insufficiency

• Very common
• Need to look for heart failure, thromboembolism,
  kidney or hepatic disease
• Otherwise, no need to pursue invasive or
  expensive testing
• Localized edema, dark pigmentation, venous stasis
  ulcers
• In venous insufficiency, veins will rapidly fill
  from above this sign is known as the
  Trendelenberg test, and supports the diagnosis
  of valvular incompetence and venous insufficiency.

OBJECTIVE Diagnose chronic venous insufficiency