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What You Should Know about the Venous System for the Physician Assistant Exam

The veins are a little easier to deal with than the arteries. For the Physician Assistant Exam (PANCE), be familiar with four venous system conditions: superficial venous thrombophlebitis, varicose veins, venous insufficiency, and deep venous thrombosis.

Superficial venous thrombophlebitis

Superficial venous thrombophlebitis is an infection of a superficial vein. The initial presentation can be redness, warmth, and pain over the vein. The treatment involves oral antibiotics and anti-inflammatories like ibuprofen (Motrin).

Varicose veins

Varicose veins are dilated superficial veins that can occur on the legs. Risk factors include obesity and occupations that involve standing for a long time. Over time, varicose veins can become painful. The affected person can also experience leg cramps.

Treatment can include venous stripping. A nonsurgical approach is the use of sclerosing agents. Anti-inflammatories also have a role in initially decreasing the inflammation.

Venous insufficiency

Venous insufficiency is usually due to an incompetent valve in the veins. Recall that the venous system includes one-way valves. As a valve works less efficiently, the person can have edema, and venous stasis can develop as a result. Risk factors include obesity. The treatment is compression stockings and weight loss.

Deep venous thrombosis

Deep venous thrombosis (DVT) commonly presents as acute swelling of an affected extremity, usually a lower extremity, although it can affect the upper extremities as well. The key to diagnosis is having a high clinical suspicion that a deep venous thrombosis may be present as well as making an appraisal of risk factors. Here are some key points concerning deep venous thrombosis:

  • Risk factors include Virchow’s triad — stasis, hypercoagulable state, and injury to the endothelium. Additional risk factors include obesity, malignancy, and taking oral contraceptive pills. Causes include a long plane ride or car trip. The keys to answering PANCE questions likely lie in the patient’s history.

  • Physical exam findings suggestive of a lower-extremity deep venous thrombosis are a Moses’ sign (also known as Bancroft’s sign) and a Homans’ sign. Note that these signs are only 50 percent predictive for a deep venous thrombosis.

  • The diagnosis of a distal deep venous thrombosis can be made with a lower-extremity Doppler venous ultrasound. It may miss more proximal deep venous thromboses (for example, in the ileofemoral area).

  • The D-dimer can help in the initial triage of a deep venous thrombosis. If the D-dimer is negative, it’s less likely that any type of deep venous thrombosis is present.

  • People who have deep venous thrombosis are at risk of pulmonary embolism. The more proximal the deep venous thrombosis, the higher the risk.

The treatment for deep venous thrombosis is heparin and warfarin (Coumadin). For an initial deep venous thrombosis, the time to be on warfarin is 3 to 6 months, depending on comorbid conditions and risk factors.

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