Okay guess you can go ahead the as you probably saw for the preceding lectures a lot

of the vasculitides are associated with infections and certainly things like we could still
diseases and so on Strong association and with a haemorrhagic type of vasculitis we're
not talking about this here here were gonna concentrate mainly on non-specific
autoimmune mainly type of vascular disorders associated and associated mainly with
vessel size so we are deliberately leaving out the ones associated with infection which
means we are leaving out a lot of usually important diseases like syphilis and you not
just to mention one but that's not at all to imply that it's not important is simply not we
can't do everything in this one-sided lecture so we were gonna approaches under the
again this is just a convenience is just help you remember it is mainly as associate a
particular type of vasculitis with vessel size and within a Gopher demos that once
associated with small vessels Armenian vessels and larger vessels in so doing the
categories in this way and usually and and what we talked about in each case are very
specific diseases of the smaller vessels merely the microscopic polyangitis choke
Strauss and when Les granulomatosis henock Shurline these very specifically Gore with
the small vessels is a lot of overlap and in order to get the impression that if you see a
perfect example of polyarthritis that it has to be always a certain vessel size and 1
million vessels will be polyarthritis Kawasaki intriguing disease burgers disease and a
larger versus the giant sell-off I just and with your arteritis rather which is a very
important disease for a couple of reasons and tackle the acyl arteritis because the
vasculitis is severely seriously involving the vessel inflammatory response the
complications of an inflamed resident to happen with these diseases so what will
happen if an vessel gets inflamed often inflammation is right from the wall it
compromises the vessel you then bleeding so not surprisingly are key mostly soft purple
little nodules on the skin you expect these things to happen thrombosis professors
included 10 still from Boise tends to get blocked up which itself can lead to problems
including lack of blood supply and infarctions as it heals as it gets better many of these
will get better even on their own this time-limited then you get scarring as as the
vascular disease and chronic ischaemia often these associated with very interesting
autoimmune immune mechanisms that cause the arthritis to cause the apparatus to
begin with and that's something you probably need to remember the vast majority of
cases which of the anchors for instance antibody related and responses which type is
associated with which disease I would certainly talk about this and plenty of detail
sometimes IgA type of reaction that's what's causing the damage and that's almost
specifically a norm is uniquely seen in Yorkshire online arteritis and of course you need
to go through the the systemic manifestations unfortunately these tend to be pretty
much the same for many of the diseases are what you have to look for when you take a
history as is the evidence of Fraser's haemoptysis as a vision coughing up blood that
tells you the lungs are involved if they're not coughing up blood then you can eliminate
whatever of the outriders don't involve the lumps you can use your clinical presentation
to help you and totally many of them overlap tremendously mileage is seen presences
on all of these diseases fever and fatigue in fact this is a classic example of fever have
known over to you will because patients often present with fever before they win or you
recognise what's going on leukocyte doses is very common C-reactive protein
remember this is a measure just of general and indicated to you of some sort of general
inflammatory response is not a very specific training similarly with the LSI sedimentation
rate of yourself these things early on God is telling you this is not psychologic this is
where this is a true systemic inflammatory response therefore your must always gonna
get and year so reaction and of course the Angus the Angus tend to fall into two type of
response is a member responsible anti-neutrophil cytoplasmic antibody so the test
involves neutrophils and you you expose them to do different forms of antibody and
here you have the myeloperoxidase type and the general ever myeloperoxidase and the
generally neutrophil or anti-protein is in the in the neutrophil and and type I
myeloperoxidase is very typical because it typically involves DD carry nuclear of the
neutrophil colchicine is very easy when you do the test because of fluorescence you
can see a distinct yellow fluorescent colour to this and and put in is is more typically
located within the cytoplasm itself so one cannot hugs the multi-located neutrophil and
while the other is more in the cytoplasm and it look like this if it's hugging the the
nucleus itself considered typical multi lobby the nucleus of the neutrophil this would be
more typically seen in view most of the small vessel vasculitides tend to produce this
reaction wears a PR throughput and is the response that is in the cytoplasm is more
typical of Webb
doses almost uniquely seen in that disease why do these things cause a problem
because it it it precipitates damage to the neutrophil once a neutrophil is damage it
ruptures it releases all its contents to granulation and the contents and the multiple and
vasoactive Princess type of materially contain tends to produce a symptomatology and
certainly produces the inflammation so when we talk about again any of these that
vasculitides we don't adopt body demographics what's the age of the patient if you see
a 12-year-old briny or you think any option all things being equal information is much
older more mature then as a whole variety of things you want to exclude which vessels
we already talked about this but specifically what part of the body if it's the aorta for
instance you think of a specific type of disease like tach if it's in the temple area as one
particular disease giant sellout riders remember which is uniquely important in that area
because that vessel can go on to supply vessels going to the iron produced blindness is
not treated properly what type of immunology are you getting especially with the anchor
antibodies what treatment you hope to apply some of these are devastating leg is going
to will kill you if you don't treat it some are self-limited and get better no matter what you
do so the prognosis is important 22 things we talk about that begin with the small vessel
once and of these four important for you to remember microscopic polyangitis chokes
trial syndrome regulars going on the terraces and the Yorkshire universal is usually less
than .1 mm very small blood vessels and because the skin is often involved is often will
give you proper do often give you problems in the kidney itself often in the
glomerulonephritis of the kidneys you can end up with necrotising up Chris centric
glomerular nephritis are no you haven't done this yet once you see the term Chris
centric look out centre glomerulonephritis is bad rapidly progressive it will kill you from
progressive glomerular nephritis haemoptysis of course you'd expect pneumatic easier
Alina by the way was the difference between these two terms what another case
anybody Glad well blood yes it's wet what you passing whereas millionaires black
coloured stool because it's coming from high up been allowed to oxidise and arthralgia
really we talked about before and so so let's take the microscopic polyangitis firstly in
one small vessel I am diseases possible triggers were not quite sure and certainly it
seems to be mainly an anchor related injury it rarely does a job on the small vessels
simply destroys them with this inflammatory response cc: plenty of neutrophils in the
vessel wall pretty well destroying the vessel wall and you end up with a Fibonacci type
of appearance in the vessel wall and and complete loss of integrity you know it's gonna
bleeding is gonna produce haemoptysis and haematuria MPO and as we say that the
commonest anchor response the myeloperoxidase anchor this disease is good in terms
of prognosis and you will get better even without treatment per treatment certainly helps
immunosuppression is what you going to target here because you know it's caused by
some sort of process related video what does it look like typical like this people get this
flat areas of haemorrhage typical purple because of this huge amount of necrosis in the
vessel wall economy to see any vessel were left tremendous amount of neutrophils
previously a particular government on exam you you are at least small vessel is likely to
be something like Polly microscopic disease the microscopic polyangitis but other things
have to be ruled out next choke Strauss very similar very similar the differences it rarely
seems to have an immune type of aetiology many of these people have as smell like
symptoms and because of this the response is not so much neutrophil it as using acrylic
if you look at the vessel wall is just infiltrated by eosinophils assessing sort of
destruction but it's mainly using so you can clearly see the difference and if you can't
make it out and we don't expect always are low-power to see neutrophils but if we tell
you it's it refers a family has oversight if we tell you it is an then that would help a lot in
coming to the right diagnosis again it's an MP or an anchor that that causing the
problem again treatment not surprisingly is immunosuppressive corticosteroids and
typically and prognosis is not bad so typically looks like this you pretty well induced the
vessel a little bit of Fibonacci necrosis of the wall that the wall is gone everything around
it is using acrylic and is just a little woman left which is probably from boys you really
have a problem
wag
on the ptosis important make sure you know everything there is to know about this
disease is hugely important why because if untreated it's fair to still an important
disease in this DNA do not dismiss people to wreck realise what did dealing with so gets
this difficultly again small vessel disease but can involve larger vessels also it's typically
an adult White's morning blackspot events are obviously aware you are aetiology and
pathogenesis anchor mediated injury no question about this but Mark now it's the MP3
anchor the earthly row okay put in his three is what's causing the anger damage it's not
an MBO and you have to get if you get this from the lab that's very helpful to get this
one of the few that our NBC anchor trouble is this form of of an inflammation that it
really does a job on on the vessel it it really tends to destroy it that citywide civility tend
to get infarction and destruction of wherever is being supplied in the others is pretty bad
too but this one is particularly necrotising is a term we often used so when you look at
the blood vessels involved Pedersen wiped out with a lot of necrosis on top of that to
further cause more damage you also get a granulomatous reaction see Geller type for
hypersensitivity response in addition to the initial inflammatory response and you get
granulomas and the granuloma's are what give it away not a lot of diseases that give
you granulomas typically things like tuberculosis histoplasmosis at anything but here it's
that different form of granuloma granulomas necrotising so the centre of the granuloma
is neutrophils rather than something like easiest necrosis is what you'd expect with
tuberculosis so it's pretty typical and of course its target organs also have respiratory
tract one-to-one three that way look for in this general area it's going to destroy the nose
destroy the upper palate I mean the stores will make a bigger hole on the palate is
gonna make a bigger hole in the lungs if you see a mass in the lungs that scattered
dating a couple things you need to immediately think about the correct matter huge the
important finding you have a lesion in the lung that's cavity thing what a phone if your
pessimist and the guy's a heavy smoker what the first thing you should think of can self
cause cancer any can send along can produce the closest counterweights audits blood
supply and then succumbed to the Void lesion in the long certainly think of cancer what
us right to colours say next stage is to colossus depending on what's involved badly
then broiled what the badge looks like of course not one would-be wedding is going
histoplasmosis don't forget histoplasmosis and tuberculosis can look tentacle get some
more lectures on this a little later on so this is a category type of lesion necrotising
lesion hi progressive and will kill you if not treated stewards are highly effective and as
white important to know what you're dealing with what happens if you get steroids and
the patient happens to have tuberculosis here rarely get it going TV love steroids it will
rapidly grow that is why treatment is simple here the opposite treatment you want to
make sure that you give immunosuppressive disease and as we see it can be a fairly
remitting comes and goes and you have to be patient with your treatment but about
disease typically looks like this a lot of neutrophils on the vessel not totally helpful just to
see this is still thinking about some black microscopic polyangitis but suddenly you see
what looks like a little granuloma wonders of the way is the multinucleated giant cells
whenever you see a bridge on your exam and as a multinucleated giant cell it's a
granuloma so question is what type is a TV granuloma is at some other time and
difference with this granular and TVs that its neutrophils it's a necrotising granuloma
that's very typical of redness what you can do here is the upper palate the whole holes
in the lungs that's pretty bad when is but you can it can certainly have of course at that
point you can get all the associated symptoms including up to 6 and haemoptysis again
your thinking cancer as you can see a suddenly underserved and gardening adding
cute about it and have a few night sweats but other than that last a little with but
suddenly I vomit all as bladder copper boilers blood you must think of cancer first if you
hold beats as horses the birds are not likely to be the answer it's forced please think of
cancer but you must rule out other things like word nerds like TV especially things that
you can treat Shurline is a fourth of the small vessel vascular today is very typical if you
get this exam say thanks because it's very easy usually goes you get the a year okay
it's not associated with an anchor the anchor should be negative but you get positive
IgM get positive IgA in the target organs businesses typically targets the kidney Tigers
the glomerulus the glomerulus SIG in it which is easy to look for so you look out for that
and of course other things are helpful typically a young person get haemorrhagic
nodular areas of haemorrhage on the skin going all the way up to the but Carey are
typically what happens with them so you can usually end up making a decent diagnosis
and with henock Shurline here is your typical purpura back at the calves node is going
all we have to the Barbican leisure glomerulus with this midnight Ms Angier increase
that takes up a PSTN or left telling you is assembling an autoimmune going on here and
it is stainless IgA it will be positive so that's a small vessel vasculitides any questions on
the sofa straightforward over and over and over again when you study are still
understood once because it's confusing unless you get this carrying your brain you tend
to confuse them let go the me media vessel me the size vessels Chief among these well
achieved but important among these STEM polyarthritis models polyarteritis carry
outriders different names for this important disease because it really can be progressive
doesn't involve the lungs typically involves everywhere else so is likely to give you
material not a lot of gut small-bowel Extend and wipe out vessels because this disease
involved in the small vessel medium sizes as disabilities aneurysms aneurysms then the
rupture and that vessel gets wiped out and you get leading patient movement present
with their purple eye with firm GI haemorrhage including in this group of courses
Kawasaki which is also an intriguing disease in bed at this plastic polyangitis verse
interesting couple of reasons one of them is the aetiology we don't know exactly how
this is how this happens but is a strong association with the hepatitis viruses B&C it's
not anger anger is going to be negative and we don't know exactly what role displays
but you must look like a patient has HPC and it is the in them then there's a possibility
that was the trigger formation of aneurysms is to the council look fanatical and are likely
sure you are next with we all vessels have little bulbs on them typical little aneurysms
on them especially renal vessels or the GI tract vessels the court further, that glomeruli
themselves are not typical involved but you can get haematuria because of the
involvement of the main part of the kidney Polly neuropathy is intriguing is that the
patient may have non-specific weakness in addition to manager the just have what
sometimes even looks like a game by type of syndrome and of course a skin paper is
not unexpected treatment with steroids is not bad this disease can be fatal this is a
serious disease but if you give stewards early on if you know for short style then you go
ahead with your treatment it's not bad it can do quite well again the way you make is
diagnosis is not some is getting a vessel and look at it at all until voluntary white looks
like in a sack but seeing these little nodules in the vasculature clear aneurysms is
extremely helpful as well in none of the vasculitides that's gonna do this expert except
for for polyarthritis does as it is about the glomeruli particularly when suddenly we get
into the substance of the kidney and the haemorrhage because of the aneurysms with
producing interstitial prices interstitial haemorrhage the vessel itself though has fairly
dramatic changes that swept February night necrosis is typically used remember this is
not a very specific thing it simply means that the vessel wall that has undergone
necrosis takes on that fibre in light colour I need a pinkish colour and it's seen better in
this disease than almost anything else suffer denied rest of the vessel is not affected a
lot of non-specific inflammation and rounded so that by advertisement is a Kawasaki's
disease is really intriguing often related to Asian Chinese people like that and it often
young of five years or less and this is one dangerous disease because this type of
inflammation we have no idea what's causing this this type of information can involve
decolonising) typically does the inflammation of the coroner's can be so widespread that
it blocks off the coroner destroys a coronary that involves in conclusion in fact just like
this is a 60-year-old with atherosclerosis this can produce in our myocardial infarction so
an infarct significant cardiovascular disease in a young person have to rule out
Kawasaki disease something that helped give you the diagnosis is the ardent presenter
the conjunctivitis this reddening of the eye we often have a strawberry type tongue the
town has riddled with a reddish colour skin rash typical often involved in adding the
butter but this is not caused by an anchor this is we don't know what's causing it
immunoglobulin helps in the treatment aspirin out of the treatment of troubles Israelis
bad if you can avoid the significant complications like NMI so typically this can go on as
we see it on my mind and is really intriguing if you see only saw one of these in my
career and this is and what happens you look at happiness as big haemorrhagic area
and when you look try to find a culinary it's all indistinguishable and blocked off because
of the haemorrhage involving the coroner again typically this rash is on the back through
the buttock flat with a conjunctivitis and a strawberry -like reddish time is a helpful things
in this remedies are young people kids Burger disease fascinating disease Eva does get
this severe pain in the hands pain mainly in the hands we don't know gain what's
causing it appears to be a hypersensitivity to smoking to cigarette smoke so look out for
that tobacco hypersensitivity beer always given this history yes I'm a heavy smoker and
yes all of a sudden my hands just started a really really painful okay that's all you have
that's fine the trouble is this involves a significant vasculitis that tends to include the
arteries in the peripheral parts of the of the limbs and the skin can get a copy of the
limbed lenders for right of this finger will turn purple and black and undergo gangrenous
change this is a very important disease because you can lose you of tours fingers very
easily if you get a severe attack this vasculitis producing inclusive necrosis we don't
know why but the history of tobacco sensitivity is invariably present if you stop smoking
that can help but it's the only thing that will help and you must completely stop smoking
it to be any progress with treatment so as you see a very dramatic disease the if you
look microscopically the inflammation serious but more important groups more
importantly you see this at close of thrombosis goes along with and finally the larger
vessel diseases of those the one rarely want to spend sometime honest temporal our
trays of giant cell outriders and the like were temporal because it suggests is only the
temporal artery is not any small vessel can be involved with this process but because
the temporal arteries is so important because it's part of the blood supply to the high
then this temporal arteritis can produce blindness and you get questions on the summer
exams all the time watch the immediate clinical significance of an attack of giants allow
tried and the answer is blindness if you don't treat promptly so I used to get a lot of
these in practice a lot of these should be sent to the lab soldiers nucleus and the patient
had obvious for been inflamed temporal artery it often bouncy just to prove that staff so
they can go ahead confidently with the treatment and the findings are very diagnostics
that is no problem making the diagnosis the giant cell arthritis is the one you really want
be attention to is certainly not limited to the temporal artery what you find on
microscopic changes are very important because radar not citrusy granulomas so that's
a second disease in which a number where has guard granulomas this also has going
not so much necrotising but week the formed granulomas with clear giant cells it's a
selling unit at injury time for hypersensitivity reaction we think the antigen maybe lasting
that were really not sure as the anchor response to this cause of this a typically blurred
vision and blindness is what to try and avoiding to look out for severe headaches
mucosal involvement of temporal artery corticosteroids are extremely helpful pointers
you need to start treatment promptly that's often weighed about this but even if you
don't I left it alone it is time limited you will get better in the meantime you get blindsided
want to put it off the point of treatment is to avoid blindness big throbbing temporal
artery with a headache is one of the significant findings and of course the fact that this
gets into the retinal artery is a reasonable default treatment and granulomas all you
have left in this temple are treated little members not applying a lot of blood at all
because the war is largely replaced my big very distinct granularity we have a bigger
fictional ego but his granuloma is a very distinct beginning of giant cells you look for
epithelioid histiocytes and that's what's happening with this all of this is taking place
right beneath the endothelium therefore it's thickening the wall and conversely
narrowing the lumen so that's giant cell arthritis that attack Basu is another intriguing
disease again youngish people of often Orientals have a predisposition to this disease
is such a runaway lookout for that when you get a history this year child
you're thinking of the Kawasaki this is Taca Yasir was different and that does this is a
disease where you again good granulomatous involvement but a far more fibrotic
response so this person comes in complaining typically of numbness in the fingers or
the BP scan of working maybe you know 100/40 on one limb and normal in the other if
you find this what you have his involvement of the aorta you have a core lactation type
of process going wrong narrowing of the aorta with this intriguing findings related to the
BP that's why the name pulseless disease involves Milliken Avenue involved in every
part of the world because he orders of fundamental to supplying blood to this systems
then you can get headaches you can get stroke like symptoms neurologic symptoms so
remember to target organ as the aorta and the responses tremendous fibrosis
granulomatosis sponsored a few bounces what you see is a fibrosis more than a
granulomatous so to get a picture and examine a lot of fibrous collagen this is from the
aorta already thinking tackle us so really destined to narrow lawmen of associates
involvement of the some of the vessels that will leave the author and again look at
college and scuppered giant cells so that's helpful if you see Jones as a finger this
probably a granuloma in the SMH trying to make a granuloma but what you see in
factors in response the collagenous response and of course a non-specific inflammation
also is a mixture of neutrophils and lymphocytes copper evidences over Rhino magnet
mainly this tremendous amount of collagen you ask how can that things from fibre
anyway, they all look exactly the same body up Oliver Lee told this is very collagenous
and once you get that information then you know what you have that combined with the
with the general systemic picture of the clinical picture should have difficult Reynard
phenomena we don't meeting about as it is important and not to be confused with
burgers disease of the crest syndrome this primary renal phenomena means you are
abnormally sensitive to temperature so if you put your hands in Coldwater Davison
righted us look like dreadful has happened and Beaverton often will give you this history
that I think you widen build red in other words as other abnormal response to the
temperature does vasospasm taking place more so time as soon as you stop
traumatising your involved limbs with hot cold water it will return to normal so there is a
clear difference here between that and there is a disease that is list tobacco -related an
Easter gangly this is a much milder process however having said this in their
submission what it looks like battery remarkable is the this plastic vessel is simply
almost completely wiped out the blood supply fortunately for just a few minutes however
there is a secondary Maynard gets a little confusing at this point the people at risk for
this after have another plan that is the so-called crest diseases remember this from
immunology calcinosis not phenomenal and softgel disabilities) the land it is these are
certain types of diseases that often will produce they set the background for secondary
renal to the point being made is if you seek relapse phenomena look out for the
possibility the patient as other precipitating disease are what have the second over
suspicion happens that systemic sclerosis remember this is a disease associated with
long fibrosis progressive fibrosis in the oesophagus typically complain that they have
more and more difficulty swallowing and there are a lot of reasonable people of the is
one of the swallowing is not necessarily systemic sclerosis and scleroderma but it could
be you have to think about it so basically that covers the vasculitides any questions on
anything or is it one bit crest and I know it's confusing responded fairly quickly you need
to really sit down and work this out in the brain one of the small vessels while the
medium of a large what's important in the symptomatology which anchor related
questions often, related to anger the nitrous NBC anchor and history fits this oneness so
just think of that with some venous disorders this one take us to long here are talking
about some extremely common diseases like varicose veins and because is common in
means a lot of people will come to you complain the varicose veins in all of the
questions that will ask you and and that's because watching a lot of TV and they have
had terms like deep-vein thrombosis and the think in our garden doomed I have this
huge amount of varicose veins I'm bound to shoot off a number of us at some point will
of course remember this is a different title very constantly these are superficial veins
that have become very close even if the clock and not going to produce the effects of
the deviant on buses these are not the clots that go to the long senior to reassure your
patient that you just fine and if you can lose a little weight and if you can now get your
feet up and can wear stockings under whatever it takes figure tremendous symptomatic
relief you can even take a whole vein out that's hardly done any more in my deed was
one of the more gruesome -looking surgeries it put out of tune down the vein given the
end then pull the whole thing out as the pursuer but it worked the Pavilion out and some
of the other veins Dr and the blood the responsibility of getting the boat out into the long
time before these begin varicose but now they have defence closing techniques that are
just as effective and hardly it strip pavilion offering more the point is this makes patients
very uncomfortable the bleed and sometimes the associate would channelise vascular
weakness in bins like haemorrhoids the rector in a canal so if you have bellicosity is of
the skin look or provide crosses somewhere else don't know why these things happen
you seen people who have a huge amount about the events and another sister who was
absolutely never so we don't know why it may be just purely genetic certainly obesity is
a fact and advancing age if the vein gets very close to the skin against irritate the skin's
development value have this tremendous irritation on the skin underneath over the
Marcoses and attended a rally get it now that can be dangerous that can even facilitate
massive haemorrhage so you want to treated to stop that from happening get persistent
to deem a tender get dystrophic vasculitis dermatitis related to discourse stasis
dermatitis the former embolism is very rare that's not a huge danger very typical in that
area but this is the one we certainly need to be concerned about deep vein thrombosis
these are the same process here we have from voices occurring in veins of the pelvis
friends and some deep in the land is not Supervalu can't palpate the vein thrombosis
you can palpate the effects of it you can palpate the thrombosis itself potentially Barry
Prost either got pelvic your sinuses but it's the deep veins and the first thing we do in
autopsy we have definite evidence of a thrombosis with embolisation and patient has
died of a pulmonary embolism since is look for this where is this the Venus producing
this so you look in the feet the galleon of the pelvis foster carer where ever you know it
can happen what predisposes you to this well everyone knows us by now if you taken a
five-hour trip on an aeroplane you don't just sit this gorgeous fall of swirly polyphonic
barometer but it is a really long trip like going to Asia 13 hours I did this once going to
Portugal almost died 13 hours on a plane simply not from but you need to get up you
need to do something need to stretch don't abuse people block your view by sieving up
and stretching doing the right thing they need you need to get up the little bit of
calisthenics in our squeeze your cards a little bit anything that gets the blood going a bit
because the stasis remember the number one thing is stasis if nothing moves in the
vascular system for several hours if you have a tendency to plot it will happen
mobilisation right after surgery is put people invariably of them barely don't do anything
that is also danger because post Sergei people tend to be a little but amenable to
clotting anyway so that's that's dangerous Case in pointers we often did this elderly
people in the old days before you have you had surgery to Tory peer and bones before
you could do entering repair of a fractured hip fracture. Could replace the hip bone was
something artificial before we had this technique the way to solve a hip fracture 90 was
to put him in bed for three months on a splint but in the three months half of them died
of luminary Emily and that was a really bad idea to post operative states put you at risk
pregnancy of course Cardiff failure moment you have failure of anything that doesn't
move that will submit drugs everyone knows birth-control pills took wife recognises but
exposure to abnormal variance of extra impetus and put you at risk clotting a lot of
young people started complaining from the November line and the customer that's huge
something like pancreatic and the cost of unifying people having migratory our clotting
migratory thrombophlebitis before you find the cancer so somebody suddenly comes to
you with this history look out for cancer and other certificate ones at the castle and a
typical underclass of causing this would be pancreatic and certain factor five mutation
because of finding if it involved the lower limb everyone knows by now typical ladders
you get reddening of the limb you get increase in size of the limb and you can measure
this get your measure out the northern measure the thickness compared also 10 to get
better get typical home and sign waves you raise a lemon and bend it over the
tremendous pain over the calf muscle so there ways of finding this and making the
diagnosis and once you have this type of thrombophlebitis from a deep vein thrombosis
then treatment is used when do you want to do is preventing blood from clotting or
weekly clot my using them the right kind of therapy so this is what you have here we
found an hour of the way with her voices in it you consider difference in size between
these two cards can be subtle you really need to measure it and if you get into the vein
of server considers big clot severely affected if this shoots often produces an embolus
and I would have called a fumble embolus then a target organ no question is the lung a
huge clot involving the bifurcations of the pulmonary artery in other words is going right
and left of involving both use" the saddle embolus in the saddle embolus is a well
recognised cause of sudden death you speak into your page and suddenly they
clutched adjust we made a shrieking sound and the dropdead that so dramatic it can be
so look out for thromboembolism of the large type reportedly most of them are small
most of the somewhere mellow shot of a small angle to the different parts of the lung
when again either produce a small infarct which is where rewire infarcts in the long
pretty rear window from thromboembolic events to the lungs and not in fact which is
what you expect to happen if you block off a pulmonary artery the double blood supply
yes at a reasonable at and this is not infrequently are some exams after the total blood
supplies go to the long and they protect the land from sudden infarction eventually you
will get an infraction but to get partially almost invariably have some preceding
preliminary cardiopulmonary disease and basically that is it was done very nicely with
finished on time and the next lecture is not until 11 and I think we better start and then
to prevent complaints from people, that I only want to do it on the deciding so we stop
here unless you have any questions on anything pretty comfortably really need to go
back yes yes well that is what's causing made it a damn involves a coronary artery
which bleeds and the bleeding can produce an obstruction and that's why you get the NI
I not romancing the questions that all you your will you find it and know you need to
make the diagnosis you basically need to do and goes you need to you need to make is
difficult that's where the the imaging studies really really helpful can pretty well see
what's going on in a colander but people are reluctant to settlement modify the order
and everything loud can't be there but the moment you see any compromise of the heart
circulation had lobbied improperly and you suspect this coronary disease you must get
in there essentially prevented approve anything else okay Seattle thank you