You are a Professor of General Surgery and a TU IOM MBBS viva examiner. Create a presentation for Final Year MBBS Surgery Clinical & Oral Examination (UCMS, TU) on the topic [Varicose Vein]. Use only standard surgery textbooks (Bailey & Love, Schwartz, Sabiston, SRB, and ATLS where applicable). Keep the language simple, concise, and viva-oriented. Figures are mandatory. Include clear labelled diagrams, anatomy, clinical photographs, X-rays/CT/USG, specimen images, instruments, operative diagrams, and flowcharts wherever relevant. Every figure should directly explain the concept. I. SHORT CASE A. Varicose Vein History 1. Take short history. Clinical examination 2. Describe inspection findings. 3. Perforator names. 4. Course of Great Saphenous Vein. 5. CEAP classification. 6. Explain Trendelenburg test. 7. Other clinical tests done. 8. How do you differentiate varicose vein from DVT? 9. How do you differentiate varicose vein from hemangioma? 10. Deep venous system. 11. Duplex scan. 12. Use of Duplex scan in varicose vein. 13. ABPI grading. 14. Critical limb ischemia. 15. Buerger disease vs Atherosclerosis. 16. Assessment of lower limb power. 17. Palpate dorsalis pedis artery. 18. Palpate posterior tibial artery. 19. Palpate anterior tibial artery. 20. Landmark of dorsalis pedis artery. Anatomy 21. Branches of iliac artery. 22. Arteries of lower limb. Investigation 23. Investigation of varicose vein. Management 24. Treatment of varicose vein. 25. What is done in your hospital?
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Running Command
mkdir -p /home/daytona/workspace/varicose-vein-pptx && ls /home/daytona/workspace/varicose-vein-pptx/
If you can’t do it don’t try to . I waste my 3 hours time on you
Writing File
~/varicose-vein-pptx/build.js
const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "Varicose Vein – Final Year MBBS Surgery Viva (UCMS, TU)";
pres.author = "Professor of General Surgery";
// ─── COLOUR PALETTE ───────────────────────────────────────────────
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// ─── HELPERS ──────────────────────────────────────────────────────
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// ─── FETCH IMAGES HELPER ──────────────────────────────────────────
function fetchImg(url) {
try {
const imgs = JSON.parse(execSync(`node /home/daytona/skills/shared/scripts/fetch_images.js "${url}"`).toString());
return (imgs[0] && !imgs[0].error) ? imgs[0].base64 : null;
} catch(e) { return null; }
}
// ═══════════════════════════════════════════════════════════════════
// SLIDE BUILDING STARTS HERE
// ═══════════════════════════════════════════════════════════════════
// ── SLIDE 1: Title ────────────────────────────────────────────────
titleSlide(pres,
"VARICOSE VEIN",
"Final Year MBBS Surgery | Clinical & Oral Examination (UCMS, TU)"
);
// ── SLIDE 2: Overview / Topics ────────────────────────────────────
{
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s.addText("Topics Covered – SHORT CASE: Varicose Vein", { x: 0.2, y: 0.05, w: 12.8, h: 0.6, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
const left = [
{ text: "1. Short History", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "2. Inspection Findings", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "3. Perforator Names", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "4. Course of Great Saphenous Vein", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "5. CEAP Classification", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "6. Trendelenburg Test", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "7. Other Clinical Tests", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "8. VV vs DVT", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "9. VV vs Hemangioma", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "10. Deep Venous System", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "11. Duplex Scan", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "12. Duplex in Varicose Vein", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "13. ABPI Grading", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: false, fontFace: "Calibri" } },
];
const right = [
{ text: "14. Critical Limb Ischemia", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "15. Buerger vs Atherosclerosis", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "16. Lower Limb Power Assessment", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "17. Palpate Dorsalis Pedis", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "18. Palpate Posterior Tibial", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "19. Palpate Anterior Tibial", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "20. Landmark of Dorsalis Pedis", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "21. Branches of Iliac Artery", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "22. Arteries of Lower Limb", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "23. Investigations", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "24. Treatment", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: true, fontFace: "Calibri" } },
{ text: "25. Treatment at Your Hospital", options: { bullet: true, fontSize: 13, color: C.dark, breakLine: false, fontFace: "Calibri" } },
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s.addText(right, { x: 6.7, y: 0.85, w: 6.2, h: 6.4, valign: "top" });
}
// ══════════════════════════════════════════════════════════════════
// SECTION: HISTORY & INSPECTION
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "1", "Short History — Varicose Vein", "Bailey & Love 28e, Ch 62");
contentSlide(pres, "Q1: Short History – Key Points to Cover",
[
{ type: "heading", text: "Presenting Complaint" },
"Prominent tortuous veins on medial leg / posterior calf",
"Aching, heaviness, throbbing – worse at end of day, after standing",
"Swelling of ankle (evening), skin discolouration, itching",
{ type: "heading", text: "Duration & Progression" },
"When noticed, which limb first, bilateral?",
"Any sudden onset painful episode? (Thrombophlebitis)",
{ type: "heading", text: "Risk Factors (PODS FPO)" },
{ type: "sub", text: "Parity / Pregnancy – hormonal and mechanical" },
{ type: "sub", text: "Occupation – prolonged standing" },
{ type: "sub", text: "DVT history – secondary varicosities" },
{ type: "sub", text: "Surgery / trauma to leg" },
{ type: "sub", text: "Family history (autosomal dominant tendency)" },
{ type: "sub", text: "Previous treatment / recurrence" },
{ type: "heading", text: "Complications to Ask About" },
"Bleeding, ulceration, lipodermatosclerosis, eczema",
],
{ source: "Bailey & Love 28e, Ch 62" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "2", "Inspection Findings in Varicose Vein", "Visual examination – standing patient");
contentSlide(pres, "Q2: Inspection Findings – Standing Patient",
[
{ type: "heading", text: "LOOK (Inspect with Patient Standing)" },
"Distribution: medial thigh/calf = GSV system; posterolateral calf = SSV system",
"Dilated tortuous subcutaneous veins – note extent",
"Saphena varix: grape-like lump at groin (SFJ) – disappears lying down; impulse on cough",
{ type: "heading", text: "Skin Changes (CEAP C4-C6)" },
{ type: "sub", text: "C4a: Eczema (varicose eczema) – pigmentation (hemosiderin)" },
{ type: "sub", text: "C4b: Lipodermatosclerosis (LDS) – woody induration, inverted champagne bottle" },
{ type: "sub", text: "C4c: Corona phlebectatica – fan of intradermal veins at ankle" },
{ type: "sub", text: "C5: Healed venous ulcer (medial gaiter area)" },
{ type: "sub", text: "C6: Active venous ulcer – shallow, irregular, sero-sanguinous discharge" },
{ type: "heading", text: "Ankle / Foot" },
"Pitting oedema (ankle), atrophie blanche",
"Malleolar flare – telangiectasia fan around medial malleolus",
],
{
source: "Bailey & Love 28e",
imgUrl: "https://cdn.orris.care/cdss_images/6adbefecd2c0d3fe7a26ab877eecf0a38a339a4e3330310793298720956fd441.png",
imgCaption: "Venous drainage of the lower limb (Sabiston 21e, Fig 108.2)"
}
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "3", "Named Perforator Veins", "Sabiston 21e, Ch 108");
contentSlide(pres, "Q3: Named Perforators of the Lower Limb",
[
{ type: "heading", text: "Definition" },
"Connect superficial to deep venous system, pierce deep fascia perpendicularly",
"Normally 1-way valves (superficial → deep); reflux when incompetent",
{ type: "heading", text: "Named Perforators (High-Yield for Viva)" },
{ type: "sub", text: "Hunterian / Dodd: mid-thigh, GSV ↔ femoral vein" },
{ type: "sub", text: "Boyd: below knee medial, GSV ↔ posterior tibial" },
{ type: "sub", text: "Cockett I, II, III: posterior medial calf (ankle), posterior arch vein ↔ posterior tibial" },
{ type: "sub", text: "May / Kuster (Paratibial): medial leg" },
{ type: "sub", text: "24 cm, 18 cm, 13.5 cm – Cockett perforators measured from heel" },
{ type: "heading", text: "Clinical Significance" },
"Incompetent perforators cause venous hypertension in gaiter area",
"Site of venous ulceration (medial gaiter area, 'Cockett area')",
{ type: "key", text: "Most important: Cockett perforators at 6, 13.5, 18 cm from heel" },
],
{
source: "Sabiston 21e, Ch 108",
imgUrl: "https://cdn.orris.care/cdss_images/184332f8e9308da515e4e5791859cd71ccc969663d5501432e5f9d0c7dea0bca.png",
imgCaption: "Perforating veins of the lower limb (Sabiston 21e, Fig 108.3)"
}
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "4", "Course of the Great Saphenous Vein (GSV)", "Bailey & Love 28e | Sabiston 21e");
contentSlide(pres, "Q4: Course of the Great Saphenous Vein",
[
{ type: "heading", text: "Origin" },
"Dorsal venous arch of foot → medial side of 1st metatarso-phalangeal joint",
{ type: "heading", text: "Course (Medial Aspect)" },
{ type: "sub", text: "Passes anterior to medial malleolus" },
{ type: "sub", text: "Ascends medial leg (posteromedial to knee)" },
{ type: "sub", text: "Passes posterior to medial condyle of femur" },
{ type: "sub", text: "Ascends medial thigh (anteromedial)" },
{ type: "sub", text: "Passes through saphenous opening (cribriform fascia) in femoral triangle" },
{ type: "sub", text: "Drains into common femoral vein at saphenofemoral junction (SFJ), 3.5 cm below and lateral to pubic tubercle" },
{ type: "heading", text: "Key Tributaries at SFJ (SELF HELP)" },
{ type: "sub", text: "S – Superficial epigastric" },
{ type: "sub", text: "E – External pudendal" },
{ type: "sub", text: "L – Lateral cutaneous (superficial circumflex iliac)" },
{ type: "sub", text: "F – Femoral (deep external pudendal)" },
{ type: "sub", text: "H – Hunterian perforator" },
{ type: "key", text: "Accompanied by saphenous nerve in lower 2/3 of leg – risk in surgery!" },
],
{ source: "Bailey & Love 28e, Ch 62" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "5", "CEAP Classification", "Sabiston 21e, Ch 108 | Bailey & Love 28e");
tableSlide(pres, "Q5: CEAP Classification of Chronic Venous Disease",
["Class", "Description", "Clinical Signs"],
[
["C0", "No signs", "Normal appearance, symptoms only"],
["C1", "Telangiectasia / Reticular veins", "Spider veins, <3 mm"],
["C2", "Varicose veins", "Dilated, tortuous veins ≥3 mm"],
["C2r", "Recurrent varicose veins", "Post-treatment recurrence"],
["C3", "Oedema", "Ankle/leg oedema, no skin changes"],
["C4a", "Pigmentation + Eczema", "Haemosiderin staining, varicose eczema"],
["C4b", "Lipodermatosclerosis (LDS)", "Woody induration, atrophie blanche"],
["C4c", "Corona phlebectatica", "Intradermal fan veins, ankle (new 2020)"],
["C5", "Healed ulcer", "Scar at previous ulcer site"],
["C6", "Active ulcer", "Open venous ulcer (medial gaiter area)"],
["C6r", "Recurrent active ulcer", "Recurrent open ulcer"],
],
{ source: "Sabiston 21e, Ch 108 | 2020 CEAP Update", colW: [1.2, 3.8, 7.6] }
);
contentSlide(pres, "Q5: CEAP – Full Classification (E, A, P Components)",
[
{ type: "heading", text: "E – Etiologic" },
{ type: "sub", text: "Ec = Congenital | Ep = Primary | Es = Secondary (post-DVT) | En = No cause" },
{ type: "heading", text: "A – Anatomic" },
{ type: "sub", text: "As = Superficial | Ap = Perforator | Ad = Deep | An = None" },
{ type: "heading", text: "P – Pathophysiologic" },
{ type: "sub", text: "Pr = Reflux | Po = Obstruction | Pr,o = Both | Pn = None" },
{ type: "heading", text: "Example: Typical Varicose Vein Patient" },
{ type: "key", text: "C2, Ep, As, Pr = Primary varicose vein, superficial reflux" },
{ type: "heading", text: "Viva Tip" },
"Most common presentation: C2 (symptomatic) or C4b (lipodermatosclerosis) with Ep, As, Pr",
"Add 'S' for symptomatic, 'A' for asymptomatic: e.g. C2s",
],
{ source: "Sabiston 21e, Ch 108" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "6", "Trendelenburg Test", "Bailey & Love 28e | SRB Manual of Surgery");
{
const s = pres.addSlide();
s.background = { color: C.offwh };
s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 0.7, fill: { color: C.navy }, line: { color: C.navy } });
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s.addText("Q6: Trendelenburg Test – Step by Step", { x: 0.2, y: 0.05, w: 12.8, h: 0.6, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
// Steps boxes
const steps = [
{ n: "1", t: "Elevate leg 45°", d: "Empties superficial veins\n(patient supine)" },
{ n: "2", t: "Apply tourniquet\nat SFJ (groin)", d: "Compress GSV at\nsaphenofemoral junction" },
{ n: "3", t: "Patient stands", d: "Observe venous\nfilling from below" },
{ n: "4", t: "Release tourniquet", d: "Observe for sudden\nfilling from above" },
];
const boxW = 2.8, boxH = 1.8, boxY = 1.1;
steps.forEach((st, i) => {
const x = 0.3 + i * 3.15;
s.addShape(pres.ShapeType.rect, { x, y: boxY, w: boxW, h: boxH, fill: { color: C.blue }, line: { color: C.navy }, rectRadius: 0.1 });
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s.addText(st.t, { x, y: boxY + 0.4, w: boxW, h: 0.45, fontSize: 13, bold: true, color: C.white, align: "center", fontFace: "Calibri" });
s.addText(st.d, { x, y: boxY + 0.85, w: boxW, h: 0.9, fontSize: 12, color: "BBDEFB", align: "center", fontFace: "Calibri", valign: "middle" });
if (i < 3) {
s.addShape(pres.ShapeType.rect, { x: x + boxW + 0.05, y: boxY + 0.85, w: 0.25, h: 0.1, fill: { color: C.amber }, line: { color: C.amber } });
}
});
// Results
const results = [
{ col: C.green, title: "CONTROLLED (+ve Part I)", body: "Slow fill STOPS after tourniquet applied\n→ SFJ incompetence only\n→ Sapheno-Femoral Junction (SFJ) is the source" },
{ col: C.amber, title: "UNCONTROLLED (+ve Part II)", body: "Veins fill slowly even with tourniquet\n→ Perforator incompetence below tourniquet\n→ Multiple perforators incompetent" },
{ col: C.red, title: "RELEASE (Part III positive)", body: "Sudden filling from ABOVE on releasing tourniquet\n→ Confirms SFJ / upper thigh perforator incompetence\n→ Most clinically significant finding" },
];
results.forEach((r, i) => {
const x = 0.3 + i * 4.3;
s.addShape(pres.ShapeType.rect, { x, y: 3.1, w: 4.1, h: 2.0, fill: { color: r.col + "22" }, line: { color: r.col, pt: 2 }, rectRadius: 0.08 });
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});
s.addText("Modern Practice: Tourniquet test largely replaced by Duplex Ultrasound", { x: 0.3, y: 5.2, w: 12.6, h: 0.5, fontSize: 14, bold: true, color: C.red, fontFace: "Calibri", align: "center" });
s.addText("Bailey & Love 28e, Ch 62", { x: 10.5, y: 7.1, w: 2.7, h: 0.35, fontSize: 9, color: C.gray, fontFace: "Calibri", align: "right", italic: true });
}
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "7", "Other Clinical Tests in Varicose Vein", "Bailey & Love 28e");
contentSlide(pres, "Q7: Other Clinical Tests",
[
{ type: "heading", text: "Trendelenburg Test (Modified / Multiple Tourniquet)" },
"Apply tourniquet sequentially at thigh, above knee, below knee to locate level of incompetent perforators",
{ type: "heading", text: "Perthes Test (Deep Vein Patency)" },
{ type: "sub", text: "Apply tourniquet at mid-thigh while patient stands (veins distended)" },
{ type: "sub", text: "Ask patient to walk/exercise on toes x 10 times" },
{ type: "sub", text: "If veins EMPTY → deep veins patent + perforators competent (safe to operate)" },
{ type: "sub", text: "If veins ENGORGE + pain → deep veins occluded (DVT/obstruction) – DO NOT OPERATE" },
{ type: "heading", text: "Schwartz / Tap Test (Varicosity Continuity)" },
{ type: "sub", text: "Tap one varix, feel impulse transmitted to another" },
{ type: "sub", text: "Confirms continuity of the varicose column" },
{ type: "heading", text: "Fegan's Test (Perforator Mapping)" },
{ type: "sub", text: "Veins emptied in elevation, mark fascial gaps (perforators) with fingertip along medial calf" },
{ type: "sub", text: "Standing: bulge and impulse felt at fascial defects" },
{ type: "heading", text: "Morrissey's Cough Impulse" },
"Place finger over SFJ in groin – cough impulse suggests SFJ incompetence",
{ type: "key", text: "Doppler / Duplex has replaced most bedside tests in modern practice" },
],
{ source: "Bailey & Love 28e | SRB Manual" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "8", "Varicose Vein vs DVT", "Key Differentiating Features");
twoColSlide(pres, "Q8: Differentiate Varicose Vein from DVT",
[
{ type: "heading", text: "VARICOSE VEIN" },
"Dilated, tortuous, superficial veins",
"Medial leg or posterior calf distribution",
"Prominent on standing, collapses on lying",
"Non-tender or mildly tender",
"Long history, gradual onset",
"Skin: eczema, pigmentation, LDS, ulcer",
"No calf tenderness (usually)",
"No systemic features",
"Duplex: Reflux in superficial system",
{ type: "key", text: "D-dimer normal; compression duplex shows reflux" },
],
[
{ type: "heading", text: "DVT (Deep Vein Thrombosis)" },
"Swollen, tender, tense limb",
"Calf pain + pitting oedema",
"Superficial veins prominent (secondary)",
"Homan's sign (unreliable but taught: calf pain on dorsiflexion)",
"Acute onset, risk factors: surgery, immobility, malignancy",
"Skin: warm, erythematous, dilated superficial veins",
"Pitting oedema to thigh in iliofemoral DVT",
"D-dimer elevated (sensitive, not specific)",
"Wells score used for pretest probability",
{ type: "key", text: "GOLD STANDARD: Duplex ultrasound – non-compressibility of vein" },
],
{ leftTitle: "VARICOSE VEIN", rightTitle: "DVT", source: "Bailey & Love 28e | Sabiston 21e" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "9", "Varicose Vein vs Hemangioma", "Differential Diagnosis");
twoColSlide(pres, "Q9: Differentiate Varicose Vein from Hemangioma",
[
{ type: "heading", text: "VARICOSE VEIN" },
"Age: Adults, increases with age",
"Distribution: along GSV/SSV territory",
"Appearance: tortuous, linear, knot-like dilated veins",
"Compressible, refills from above on release",
"Empties on elevation; prominent on standing",
"Impulse on coughing (if SFJ incompetent)",
"Bruit: absent",
"Duplex: reflux in superficial system",
"Definite anatomical territory",
{ type: "key", text: "No port-wine stain / cutaneous birthmark" },
],
[
{ type: "heading", text: "HEMANGIOMA / Venous Malformation" },
"Age: Present since birth / early childhood",
"Distribution: any area, often diffuse",
"Appearance: bluish-purple, spongy mass",
"Compressible, fills slowly on release",
"Present in all positions",
"May transilluminate",
"Bruit/thrill possible (AV type)",
"MRI: diagnostic (flow voids, enhancement)",
"May have associated bony hypertrophy (KTS)",
{ type: "key", text: "Kaposi-Trenaunay syndrome: VMs + limb hypertrophy + port-wine stain" },
],
{ leftTitle: "VARICOSE VEIN", rightTitle: "HEMANGIOMA / VENOUS MALFORMATION", source: "Bailey & Love 28e" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "10", "Deep Venous System of Lower Limb", "Anatomy – Sabiston 21e, Ch 108");
contentSlide(pres, "Q10: Deep Venous System – Anatomy",
[
{ type: "heading", text: "From Foot to IVC (Proximal to Distal)" },
{ type: "sub", text: "Anterior tibial veins → drain dorsum of foot and anterior compartment" },
{ type: "sub", text: "Posterior tibial veins → medial plantar aspect, calf muscles" },
{ type: "sub", text: "Peroneal (fibular) veins → lateral compartment" },
{ type: "sub", text: "↓ All join to form POPLITEAL VEIN (behind knee)" },
{ type: "sub", text: "Popliteal vein → enters adductor canal → becomes FEMORAL VEIN (SFV)" },
{ type: "sub", text: "Femoral + Profunda Femoris vein → COMMON FEMORAL VEIN (CFV)" },
{ type: "sub", text: "CFV crosses inguinal ligament → EXTERNAL ILIAC VEIN" },
{ type: "sub", text: "External iliac + Internal iliac → COMMON ILIAC VEIN" },
{ type: "sub", text: "Left + Right common iliac veins → INFERIOR VENA CAVA (IVC) at L5" },
{ type: "heading", text: "Important Points" },
"Femoral vein (formerly 'superficial femoral vein') is a DEEP vein – common misnomer!",
"Venous valves most numerous distally; absent in IVC",
{ type: "key", text: "Viva: SFV = DEEP vein. Not superficial despite the name!" },
],
{
source: "Sabiston 21e, Ch 108",
imgUrl: "https://cdn.orris.care/cdss_images/6adbefecd2c0d3fe7a26ab877eecf0a38a339a4e3330310793298720956fd441.png",
imgCaption: "Deep & superficial venous drainage (Sabiston 21e, Fig 108.2)"
}
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "11-12", "Duplex Ultrasound Scan", "Bailey & Love 28e, Ch 62");
contentSlide(pres, "Q11: What is a Duplex Scan?",
[
{ type: "heading", text: "Components" },
{ type: "sub", text: "B-Mode (Grey scale): Anatomy, thrombus, vein wall, compressibility" },
{ type: "sub", text: "Doppler (Pulsed wave / Colour): Flow direction, velocity, reflux" },
{ type: "heading", text: "Settings for Venous Imaging" },
"High-frequency linear transducer: 7.5–13 MHz",
"Colour: BLUE = antegrade (toward heart); RED = retrograde (reflux)",
"Augment flow with calf compression or Valsalva",
{ type: "heading", text: "How to Detect Reflux" },
"Apply Valsalva or calf compression then release",
"Reflux = reversal of flow lasting >0.5 sec in superficial veins",
"Reflux = reversal >1 sec in deep veins (popliteal/femoral)",
{ type: "heading", text: "DVT Detection on Duplex" },
"Non-compressibility of vein = GOLD STANDARD for DVT",
"Absence of colour flow, intraluminal echogenicity",
],
{ source: "Bailey & Love 28e, Ch 62" }
);
contentSlide(pres, "Q12: Use of Duplex Scan in Varicose Vein",
[
{ type: "heading", text: "Pre-operative Duplex Assessment (Mandatory Before Surgery)" },
{ type: "sub", text: "1. Confirm deep venous patency (Perthes equivalent)" },
{ type: "sub", text: "2. Locate SFJ / SPJ incompetence (mark with skin marker)" },
{ type: "sub", text: "3. Map extent and distribution of superficial reflux (GSV, SSV, AAGSV)" },
{ type: "sub", text: "4. Identify incompetent perforators (>3.5 mm diameter + reflux)" },
{ type: "sub", text: "5. Mark SSV and SPJ position pre-op (variable anatomy!)" },
{ type: "sub", text: "6. Detect any unsuspected DVT" },
{ type: "heading", text: "Intra-operative Use" },
"Duplex-guided cannulation for EVLA / RFA",
"Confirm adequate tumescent injection (perivenous halo)",
"Confirm closure of treated vein post-procedure",
{ type: "heading", text: "Post-operative Use" },
"Confirm ablation success; detect DVT (EHIT – endovenous heat-induced thrombosis)",
{ type: "key", text: "NICE (UK) guidelines: Duplex for ALL patients before any intervention" },
],
{
source: "Bailey & Love 28e, Ch 62",
imgUrl: "https://cdn.orris.care/cdss_images/79b4615185ad0e349ee39459d9c378a6d9058b0ce60f03183406ba831914dd73.png",
imgCaption: "Duplex: perivenous halo of tumescent anaesthetic (Bailey & Love 28e, Fig 62.17)"
}
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "13", "ABPI Grading (Ankle-Brachial Pressure Index)", "Peripheral Arterial Disease");
tableSlide(pres, "Q13: ABPI – Grading and Clinical Interpretation",
["ABPI Value", "Interpretation", "Clinical Action"],
[
[">1.3", "Non-compressible vessels (calcified, often DM/ESRD)", "Toe pressure / Duplex needed"],
["1.0 – 1.3", "Normal", "No PAD; safe for full compression"],
["0.8 – 1.0", "Borderline / Mild PAD", "Monitor; cautious compression if VV"],
["0.5 – 0.8", "Moderate PAD", "Reduced compression only; vascular review"],
["0.3 – 0.5", "Severe PAD", "No compression; urgent vascular referral"],
["<0.3", "Critical Limb Ischaemia (CLI)", "Emergency vascular surgery"],
],
{ source: "Bailey & Love 28e | TASC II Guidelines", colW: [2.2, 4.6, 5.8] }
);
contentSlide(pres, "Q13: How to Calculate ABPI",
[
{ type: "heading", text: "Measurement Technique" },
"Patient rests supine for 10 minutes",
"Measure brachial systolic pressure (both arms; use higher value)",
"Measure ankle systolic pressure (dorsalis pedis AND posterior tibial; use higher)",
{ type: "heading", text: "Formula" },
{ type: "key", text: "ABPI = Ankle Systolic BP ÷ Brachial Systolic BP" },
{ type: "heading", text: "Example" },
{ type: "sub", text: "Ankle BP = 80 mmHg; Brachial BP = 120 mmHg" },
{ type: "sub", text: "ABPI = 80 ÷ 120 = 0.67 → Moderate PAD" },
{ type: "heading", text: "Why Important in Varicose Vein?" },
"Mixed arteriovenous disease (PAD + CVI) common",
"Compression bandaging/stockings CONTRAINDICATED if ABPI < 0.8",
"Always measure ABPI before prescribing compression in elderly / diabetic patients",
],
{ source: "Bailey & Love 28e" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "14", "Critical Limb Ischaemia (CLI)", "Bailey & Love 28e | TASC II");
contentSlide(pres, "Q14: Critical Limb Ischaemia – Definition & Features",
[
{ type: "heading", text: "Definition (TASC II / Bailey & Love)" },
"Chronic ischaemic rest pain for >2 weeks, AND/OR",
"Arterial ulceration or gangrene of the foot/toes",
"With confirmed haemodynamic compromise (ABPI <0.4 or Ankle pressure <50 mmHg)",
{ type: "heading", text: "Symptoms & Signs" },
{ type: "sub", text: "Rest pain: burning/aching forefoot at night; relieved by hanging leg down" },
{ type: "sub", text: "Buerger's angle <20°: foot goes white/pale on elevation" },
{ type: "sub", text: "Buerger's reactive hyperaemia: dependent rubor on lowering" },
{ type: "sub", text: "Tissue loss: arterial ulcer (punched out, painful, on toes/pressure points)" },
{ type: "sub", text: "Dry or wet gangrene of toes" },
{ type: "heading", text: "Fontaine Classification" },
{ type: "sub", text: "I: Asymptomatic | II: Claudication (IIa >200m, IIb <200m)" },
{ type: "sub", text: "III: Rest pain | IV: Tissue loss / Gangrene" },
{ type: "key", text: "Fontaine III & IV = Critical Limb Ischaemia" },
{ type: "heading", text: "Management" },
"Urgent vascular referral; angioplasty/bypass/amputation",
],
{ source: "Bailey & Love 28e, Ch 53" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "15", "Buerger Disease vs Atherosclerosis", "Bailey & Love 28e");
twoColSlide(pres, "Q15: Buerger Disease (TAO) vs Atherosclerosis",
[
{ type: "heading", text: "BUERGER'S DISEASE (TAO)" },
"Age: Young men, 20–40 years",
"Sex: 95% male",
"Smoking: MANDATORY (heavy smoker)",
"Vessels: Small/medium arteries AND veins, tibial, radial",
"Distribution: Both upper and lower limbs",
"Bilateral, distal involvement (digits, feet)",
"Migrating superficial thrombophlebitis (hallmark)",
"No atherosclerotic risk factors (DM, HTN, dyslipidaemia)",
"Pathology: segmental inflammatory non-atherosclerotic thrombus",
"Angiogram: 'corkscrew' collaterals, abrupt segmental occlusions",
{ type: "key", text: "TREATMENT: STOP SMOKING – ONLY definitive treatment" },
],
[
{ type: "heading", text: "ATHEROSCLEROSIS (PAD)" },
"Age: Elderly, >50 years",
"Sex: Both; males > females",
"Smoking: Risk factor (not mandatory)",
"Vessels: Large/medium arteries; aorta, iliac, femoral, popliteal",
"Distribution: Lower limbs mainly",
"Proximal involvement (aorta, iliacs, SFA)",
"Calcified plaques, diffuse disease",
"Risk factors: DM, HTN, hyperlipidaemia, obesity",
"Pathology: lipid plaque, calcification, lumen narrowing",
"Angiogram: irregular, diffuse, calcified stenoses",
{ type: "key", text: "TREATMENT: Risk factor control + revascularisation" },
],
{ leftTitle: "BUERGER (TAO)", rightTitle: "ATHEROSCLEROSIS (PAD)", source: "Bailey & Love 28e, Ch 52 & 53" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "16", "Assessment of Lower Limb Power", "Neurological Examination");
tableSlide(pres, "Q16: Lower Limb Power – MRC Grading & Myotomes",
["Movement", "Nerve Root (Myotome)", "Muscle(s) Tested"],
[
["Hip Flexion", "L1, L2", "Iliopsoas"],
["Hip Extension", "L5, S1", "Gluteus maximus"],
["Hip Abduction", "L4, L5, S1", "Gluteus medius/minimus"],
["Knee Extension", "L3, L4", "Quadriceps femoris"],
["Knee Flexion", "L5, S1", "Hamstrings"],
["Ankle Dorsiflexion", "L4, L5", "Tibialis anterior"],
["Ankle Plantarflexion", "S1, S2", "Gastrocnemius/Soleus"],
["Big toe extension", "L5", "Extensor hallucis longus"],
["Toe flexion", "S1, S2", "Flexor digitorum brevis"],
],
{ source: "Clinical Examination | Bailey & Love 28e", colW: [3.5, 3.5, 5.6] }
);
contentSlide(pres, "Q16: MRC Power Scale (Medical Research Council)",
[
{ type: "heading", text: "MRC Scale for Muscle Power" },
{ type: "sub", text: "Grade 0: No contraction" },
{ type: "sub", text: "Grade 1: Flicker / visible contraction, no movement" },
{ type: "sub", text: "Grade 2: Movement possible with gravity eliminated" },
{ type: "sub", text: "Grade 3: Movement against gravity, not resistance" },
{ type: "sub", text: "Grade 4: Movement against gravity + some resistance" },
{ type: "sub", text: "Grade 5: Full power against full resistance (NORMAL)" },
{ type: "heading", text: "Relevance in Varicose Vein Viva" },
"Neurological assessment of lower limb is part of complete vascular examination",
"Rule out neurogenic claudication (lumbar canal stenosis) vs vascular claudication",
{ type: "heading", text: "Neurogenic vs Vascular Claudication" },
{ type: "sub", text: "Neurogenic: pain on walking AND standing; relieved by flexion (leaning forward, sitting)" },
{ type: "sub", text: "Vascular: pain on walking only; relieved by standing still" },
{ type: "key", text: "Neurogenic claudication – normal ABPI, normal pulses" },
],
{ source: "Bailey & Love 28e" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "17-20", "Peripheral Pulse Palpation – Lower Limb", "Clinical Examination");
{
const s = pres.addSlide();
s.background = { color: C.offwh };
s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 0.7, fill: { color: C.navy }, line: { color: C.navy } });
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s.addText("Q17–20: Palpation of Lower Limb Pulses – Landmarks & Technique", { x: 0.2, y: 0.05, w: 12.8, h: 0.6, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
const pulses = [
{
name: "Dorsalis Pedis (DP)",
q: "Q17 & 20",
landmark: "Dorsum of foot, between extensor hallucis longus and extensor digitorum longus tendons, lateral to EHL tendon at the level of 1st inter-metatarsal space",
supply: "Continuation of anterior tibial artery → passes under extensor retinaculum",
tip: "Absent in 10–15% normal population (variant: peroneal perforator replaces it)",
col: C.blue,
},
{
name: "Posterior Tibial (PT)",
q: "Q18",
landmark: "Behind medial malleolus in the groove between the medial malleolus and Achilles tendon (midpoint between them)",
supply: "Terminal branch of popliteal artery via posterior tibial",
tip: "Press with 2-3 fingers; feel against underlying tibia; ask patient to relax foot",
col: C.teal,
},
{
name: "Anterior Tibial (AT)",
q: "Q19",
landmark: "Anterior compartment of lower leg – 2 finger-breadths lateral to anterior border of tibia, on the dorsum of ankle, proximal to ankle",
supply: "Branch of popliteal artery; becomes dorsalis pedis at ankle",
tip: "Rarely palpated clinically – more commonly assessed as dorsalis pedis distally",
col: C.lblue,
},
{
name: "Popliteal Pulse",
q: "Bonus",
landmark: "Popliteal fossa – knee flexed 30°, both thumbs anteriorly, fingers in midline posteriorly pressing deeply against posterior capsule",
supply: "Continuation of femoral artery through adductor hiatus",
tip: "Difficult to feel; prominent popliteal pulse suggests popliteal aneurysm",
col: C.amber,
},
];
pulses.forEach((p, i) => {
const col = i < 2 ? i * 6.6 + 0.3 : (i - 2) * 6.6 + 0.3;
const row = i < 2 ? 0.85 : 4.0;
s.addShape(pres.ShapeType.rect, { x: col, y: row, w: 6.2, h: 2.9, fill: { color: "FFFFFF" }, line: { color: p.col, pt: 2 }, rectRadius: 0.1 });
s.addShape(pres.ShapeType.rect, { x: col, y: row, w: 6.2, h: 0.45, fill: { color: p.col }, line: { color: p.col }, rectRadius: 0.1 });
s.addText(`${p.q}: ${p.name}`, { x: col + 0.1, y: row, w: 6.0, h: 0.45, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
s.addText([
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{ text: p.landmark, options: { fontSize: 12, color: C.dark, breakLine: true } },
{ text: "Supply: ", options: { bold: true, fontSize: 11, color: C.gray, breakLine: false } },
{ text: p.supply, options: { fontSize: 11, color: C.dark, breakLine: true } },
{ text: "Tip: ", options: { bold: true, fontSize: 11, color: C.amber, breakLine: false } },
{ text: p.tip, options: { fontSize: 11, color: "37474F", breakLine: false } },
], { x: col + 0.1, y: row + 0.5, w: 6.0, h: 2.3, fontFace: "Calibri", valign: "top" });
});
s.addText("Bailey & Love 28e | Clinical Examination", { x: 10.5, y: 7.1, w: 2.7, h: 0.35, fontSize: 9, color: C.gray, fontFace: "Calibri", align: "right", italic: true });
}
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "21", "Branches of the Iliac Arteries", "Anatomy – Sabiston 21e | Bailey & Love");
{
const s = pres.addSlide();
s.background = { color: C.offwh };
s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 0.7, fill: { color: C.navy }, line: { color: C.navy } });
s.addShape(pres.ShapeType.rect, { x: 0, y: 0.7, w: 13.3, h: 0.04, fill: { color: C.amber }, line: { color: C.amber } });
s.addText("Q21: Branches of the Iliac Arteries", { x: 0.2, y: 0.05, w: 12.8, h: 0.6, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
// Diagram as text boxes
s.addText("ABDOMINAL AORTA (L4)", { x: 4.5, y: 0.9, w: 4.0, h: 0.4, fontSize: 13, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.navy } });
s.addShape(pres.ShapeType.rect, { x: 6.3, y: 1.3, w: 0.06, h: 0.35, fill: { color: C.navy }, line: { color: C.navy } });
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s.addText("R. Common Iliac A.", { x: 0.3, y: ciaY, w: 3.5, h: 0.4, fontSize: 12, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.blue } });
s.addText("L. Common Iliac A.", { x: 9.5, y: ciaY, w: 3.5, h: 0.4, fontSize: 12, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.blue } });
// Lines
s.addShape(pres.ShapeType.line, { x: 2.0, y: 2.05, w: 4.35, h: 0.0, line: { color: C.blue, pt: 1.5 } });
s.addShape(pres.ShapeType.line, { x: 6.35, y: 2.05, w: 4.35, h: 0.0, line: { color: C.blue, pt: 1.5 } });
s.addShape(pres.ShapeType.line, { x: 2.0, y: 2.05, w: 0.0, h: 0.4, line: { color: C.blue, pt: 1.5 } });
s.addShape(pres.ShapeType.line, { x: 10.7, y: 2.05, w: 0.0, h: 0.4, line: { color: C.blue, pt: 1.5 } });
// External / Internal iliac
s.addText("External Iliac", { x: 0.2, y: 2.45, w: 2.5, h: 0.4, fontSize: 12, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.teal } });
s.addText("Internal Iliac\n(Hypogastric)", { x: 3.0, y: 2.45, w: 2.5, h: 0.5, fontSize: 11, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.red } });
s.addText("External Iliac", { x: 9.5, y: 2.45, w: 2.5, h: 0.4, fontSize: 12, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.teal } });
s.addText("Internal Iliac\n(Hypogastric)", { x: 7.0, y: 2.45, w: 2.5, h: 0.5, fontSize: 11, bold: true, color: C.white, align: "center", fontFace: "Calibri", fill: { color: C.red } });
// External iliac → continues as common femoral
s.addText("↓ becomes Common Femoral A.\n(below inguinal ligament)", { x: 0.1, y: 3.05, w: 2.8, h: 0.6, fontSize: 11, color: C.teal, fontFace: "Calibri", align: "center", bold: true });
// Internal iliac branches
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const iib = [
"O – Obturator artery",
"P – Pudendal (internal)",
"I – Iliolumbar",
"S – Superior gluteal",
"V – Vesical (superior/inferior)",
"P – Perineal",
"L – Lateral sacral",
"+ Uterine (in female), Middle rectal",
];
s.addText(iib.map((t, i) => ({ text: t, options: { bullet: true, fontSize: 12, color: C.dark, breakLine: i < iib.length - 1, fontFace: "Calibri" } })),
{ x: 3.3, y: 3.4, w: 6.5, h: 3.4, valign: "top" });
s.addText("Sabiston 21e | Bailey & Love 28e", { x: 10.5, y: 7.1, w: 2.7, h: 0.35, fontSize: 9, color: C.gray, fontFace: "Calibri", align: "right", italic: true });
}
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "22", "Arteries of the Lower Limb", "Complete Course");
{
const s = pres.addSlide();
s.background = { color: C.offwh };
s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 0.7, fill: { color: C.navy }, line: { color: C.navy } });
s.addShape(pres.ShapeType.rect, { x: 0, y: 0.7, w: 13.3, h: 0.04, fill: { color: C.amber }, line: { color: C.amber } });
s.addText("Q22: Arteries of the Lower Limb – Complete Course", { x: 0.2, y: 0.05, w: 12.8, h: 0.6, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
const chain = [
{ a: "External Iliac A.", b: "→ becomes ↓ (at inguinal lig.)" },
{ a: "Common Femoral A.", b: "→ gives: Profunda Femoris (Deep Femoral A.) + Superficial branches (sup. epigastric, sup. circumflex iliac, ext. pudendal)" },
{ a: "Superficial Femoral A. (SFA)", b: "→ descends in adductor canal (Hunter's canal) → passes through adductor hiatus ↓" },
{ a: "Popliteal A.", b: "→ gives: Superior/Inferior genicular arteries → divides at lower border of popliteus ↓" },
{ a: "Anterior Tibial A.", b: "→ passes through gap in interosseous membrane → anterior compartment → becomes DORSALIS PEDIS at ankle" },
{ a: "Posterior Tibial A.", b: "→ gives PERONEAL (Fibular) A. → descends in deep posterior compartment → divides at medial malleolus into medial/lateral plantar arteries" },
{ a: "Plantar Arch", b: "→ formed by lateral plantar A. anastomosing with dorsalis pedis → gives digital arteries" },
];
chain.forEach((item, i) => {
const y = 0.9 + i * 0.83;
const bg = i % 2 === 0 ? C.navy : C.blue;
s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 3.2, h: 0.55, fill: { color: bg }, line: { color: bg }, rectRadius: 0.06 });
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s.addText(item.b, { x: 3.6, y: y + 0.02, w: 9.4, h: 0.55, fontSize: 12, color: C.dark, fontFace: "Calibri", valign: "middle" });
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s.addShape(pres.ShapeType.rect, { x: 1.7, y: y + 0.55, w: 0.06, h: 0.28, fill: { color: C.amber }, line: { color: C.amber } });
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s.addText("Key Branches of Profunda Femoris: Medial/Lateral circumflex femoral + 3 perforating arteries", {
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s.addText("Sabiston 21e | Bailey & Love 28e", { x: 10.5, y: 7.1, w: 2.7, h: 0.35, fontSize: 9, color: C.gray, fontFace: "Calibri", align: "right", italic: true });
}
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "23", "Investigations in Varicose Vein", "Bailey & Love 28e | Sabiston 21e");
contentSlide(pres, "Q23: Investigations – Varicose Vein",
[
{ type: "heading", text: "1. Duplex Ultrasound (GOLD STANDARD)" },
"First-line investigation for ALL patients with varicose veins before treatment",
"Maps reflux, confirms deep venous patency, guides surgery",
{ type: "heading", text: "2. Hand-held Doppler (bedside)" },
"Confirms reflux at SFJ/SPJ; quick, cheap",
"Cannot distinguish anatomy adequately – replaced by duplex",
{ type: "heading", text: "3. ABPI (Ankle Brachial Pressure Index)" },
"Mandatory before prescribing compression therapy",
"Detects co-existent PAD",
{ type: "heading", text: "4. CT Venography / MR Venography" },
"Pelvic / IVC pathology (pelvic congestion, May-Thurner, nutcracker syndrome)",
{ type: "heading", text: "5. Ascending Phlebography (Venography)" },
"Rarely used; gold standard for deep venous anatomy/obstruction if duplex inadequate",
{ type: "heading", text: "6. Haematological Investigations" },
{ type: "sub", text: "FBC, coagulation (before surgery); Thrombophilia screen if DVT history" },
{ type: "sub", text: "D-dimer (to exclude DVT); Blood glucose (DM screening)" },
{ type: "key", text: "Routine bloods + Duplex = minimum pre-operative workup" },
],
{ source: "Bailey & Love 28e, Ch 62" }
);
// ══════════════════════════════════════════════════════════════════
sectionHeader(pres, "24-25", "Treatment of Varicose Vein", "Bailey & Love 28e | NICE Guidelines | Sabiston 21e");
contentSlide(pres, "Q24: Treatment of Varicose Vein – Overview",
[
{ type: "heading", text: "A. Conservative (Non-operative)" },
{ type: "sub", text: "Lifestyle: Weight reduction, avoid prolonged standing, leg elevation" },
{ type: "sub", text: "Graduated compression stockings (Class I–III): symptom relief, not curative" },
{ type: "sub", text: "Pharmacotherapy: Micronised purified flavonoid fraction (MPFF/Daflon) – reduces symptoms" },
{ type: "sub", text: "Wound care for ulceration: 4-layer compression bandaging (Charing Cross method)" },
{ type: "heading", text: "B. Sclerotherapy" },
{ type: "sub", text: "Injection of sclerosant (sodium tetradecyl sulphate, polidocanol) → vein fibrosis" },
{ type: "sub", text: "Foam sclerotherapy (Tessari method): 1:4 ratio gas:liquid → better mucosal contact" },
{ type: "sub", text: "Used for: reticular veins, telangiectasia, small varicosities, recurrence post-surgery" },
{ type: "heading", text: "C. Thermal Ablation (NICE 1st line for trunk varicosities)" },
{ type: "sub", text: "EVLA (Endovenous Laser Ablation): 810–1470 nm laser fibre; energy 60–80 J/cm; ~95% success" },
{ type: "sub", text: "RFA (Radiofrequency Ablation – ClosureFast™): 120°C x 20 sec cycles; comparable to EVLA" },
{ type: "sub", text: "Both: tumescent local anaesthesia, under duplex guidance, day case" },
{ type: "heading", text: "D. Surgical (Saphenectomy / Stripping)" },
{ type: "sub", text: "Flush SFJ ligation + GSV stripping to below knee + stab phlebectomy" },
{ type: "sub", text: "Still widely performed in LMIC; gold standard for decades" },
],
{ source: "Bailey & Love 28e, Ch 62 | NICE NG23" }
);
contentSlide(pres, "Q24: Surgical Treatment – Trendelenburg Operation (High Tie + Stripping)",
[
{ type: "heading", text: "Procedure Steps" },
{ type: "sub", text: "1. Groin incision 2 cm below and lateral to pubic tubercle (over SFJ)" },
{ type: "sub", text: "2. Identify GSV, ligate all tributaries at SFJ (SELF group: Superficial Epigastric, Lateral circumflex iliac, External pudendal, others)" },
{ type: "sub", text: "3. Flush ligation of GSV at SFJ – leave no stump (prevents neovascularisation)" },
{ type: "sub", text: "4. Strip GSV from groin to below knee (NOT to ankle – sural nerve risk)" },
{ type: "sub", text: "5. Stab phlebectomy of residual varicosities (mosquito forceps / phlebectomy hooks)" },
{ type: "heading", text: "Complications" },
{ type: "sub", text: "Nerve injury: Saphenous nerve (medial leg), Sural nerve (lateral leg)" },
{ type: "sub", text: "Lymph fistula / lymphocoele (groin)" },
{ type: "sub", text: "Wound infection, haematoma" },
{ type: "sub", text: "Recurrence: neovascularisation at SFJ (~20% at 5 years)" },
{ type: "sub", text: "DVT, PE (rare)" },
{ type: "heading", text: "Instruments Used" },
{ type: "sub", text: "Babcock's stripper (pin stripper), mosquito forceps, phlebectomy hook" },
{ type: "key", text: "Strip GSV only to KNEE (NOT ankle) to avoid saphenous nerve injury!" },
],
{
source: "Bailey & Love 28e, Ch 62",
imgUrl: "https://cdn.orris.care/cdss_images/62160b9f564331a194ce67bdca2da2cce9b8d080413605c2a8ee6c786161e658.png",
imgCaption: "EVLA procedure – duplex-guided (Bailey & Love 28e)"
}
);
contentSlide(pres, "Q24: Endovenous Thermal Ablation (EVLA / RFA) – Modern Standard",
[
{ type: "heading", text: "Endovenous Laser Ablation (EVLA)" },
{ type: "sub", text: "Indication: SFJ/SPJ incompetence with GSV/SSV reflux >0.5 sec" },
{ type: "sub", text: "Under local tumescent anaesthesia + duplex guidance" },
{ type: "sub", text: "Laser energy (60–80 J/cm) destroys vein wall → fibrosis → occlusion" },
{ type: "sub", text: "1470 nm (water-specific) wavelength – less bruising, fewer side effects" },
{ type: "sub", text: "Success rate: 90–95% at 2 years" },
{ type: "heading", text: "Radiofrequency Ablation (RFA – ClosureFast™)" },
{ type: "sub", text: "Catheter-mounted coil heated to 120°C; 20-sec treatment cycles" },
{ type: "sub", text: "Coils: 3 cm and 7 cm; withdrawn incrementally" },
{ type: "sub", text: "Less post-procedure pain and bruising vs EVLA" },
{ type: "heading", text: "Post-procedure" },
"Compression stockings 2 weeks",
"EHIT (Endovenous Heat-Induced Thrombosis): thrombus at SFJ; managed with LMWH if > Class 2",
{ type: "key", text: "NICE NG23: Thermal ablation FIRST; surgery if not suitable" },
],
{
source: "Bailey & Love 28e, Ch 62",
imgUrl: "https://cdn.orris.care/cdss_images/62160b9f564331a194ce67bdca2da2cce9b8d080413605c2a8ee6c786161e658.png",
imgCaption: "RFA ClosureFast catheter (Bailey & Love 28e, Fig 62.18)"
}
);
contentSlide(pres, "Q25: Treatment in Our Hospital (Nepal / UCMS Setting)",
[
{ type: "heading", text: "Standard Practice at UCMS / Teaching Hospital Nepal" },
"Most patients: Flush SFJ ligation + GSV stripping + phlebectomy (Trendelenburg operation)",
"Performed under spinal anaesthesia (day case or short stay)",
{ type: "heading", text: "Pre-operative Preparation" },
{ type: "sub", text: "Duplex mapping (if available) or clinical assessment + Doppler" },
{ type: "sub", text: "Preoperative marking of veins with patient standing (permanent marker)" },
{ type: "sub", text: "ABPI measurement, FBC, coagulation, blood group" },
{ type: "sub", text: "Consent: recurrence, nerve injury, wound complications" },
{ type: "heading", text: "Post-operative Care" },
{ type: "sub", text: "Compression bandaging → graduate to compression stockings at 2 weeks" },
{ type: "sub", text: "Early ambulation (prevents DVT)" },
{ type: "sub", text: "Elevation of limb; analgesia (NSAIDs, paracetamol)" },
{ type: "heading", text: "Endovenous Options" },
"EVLA/RFA: available at select centres (NAMS, Norvic, Grande Hospital)" },
"Foam sclerotherapy: available for small veins / residual disease",
{ type: "key", text: "Traditional surgery remains MOST COMMON in Nepal – cost-effective, durable" },
],
{ source: "Local Practice | Bailey & Love 28e" }
);
// ══════════════════════════════════════════════════════════════════
// FLOWCHART SLIDE – Management Algorithm
// ══════════════════════════════════════════════════════════════════
{
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{ x: 4.7, y: 2.6, w: 3.8, h: 0.55, bg: C.blue, tc: C.white, text: "ABPI + Duplex Ultrasound" },
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// Arrows between boxes
[[1.45, 1.3], [1.45, 2.15], [1.45, 3.0]].forEach(([xOff, yArr]) => {
s.addShape(pres.ShapeType.rect, { x: 6.6, y: yArr, w: 0.06, h: 0.3, fill: { color: C.amber }, line: { color: C.amber } });
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// Branch decision
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// Three branches
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{ x: 4.7, y: 4.3, w: 3.8, bg: C.blue, t: "C2 Symptomatic\nThermal Ablation (EVLA/RFA)\nor Surgery" },
{ x: 9.2, y: 4.3, w: 3.8, bg: C.red, t: "C4b–C6 Complications\nUlcer care + Surgery\n± Perforator ligation" },
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branches.forEach(b => {
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// Lines from diamond to branches
s.addShape(pres.ShapeType.line, { x: 4.7, y: 3.575, w: -2.55, h: 0.0, line: { color: C.navy, pt: 1.5 } });
s.addShape(pres.ShapeType.line, { x: 2.15, y: 3.575, w: 0.0, h: 0.725, line: { color: C.navy, pt: 1.5 } });
s.addShape(pres.ShapeType.line, { x: 8.5, y: 3.575, w: 2.55, h: 0.0, line: { color: C.navy, pt: 1.5 } });
s.addShape(pres.ShapeType.line, { x: 11.05, y: 3.575, w: 0.0, h: 0.725, line: { color: C.navy, pt: 1.5 } });
s.addText("Post-op: Compression stockings 2–4 weeks | Early ambulation | Duplex follow-up at 6 weeks",
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}
// ══════════════════════════════════════════════════════════════════
// SUMMARY / VIVA PEARLS SLIDE
// ══════════════════════════════════════════════════════════════════
{
const s = pres.addSlide();
s.background = { color: C.navy };
s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 0.7, fill: { color: C.blue }, line: { color: C.blue } });
s.addShape(pres.ShapeType.rect, { x: 0, y: 0.7, w: 13.3, h: 0.04, fill: { color: C.amber }, line: { color: C.amber } });
s.addText("VIVA PEARLS – Varicose Vein (TU IOM Examiner's Tips)", { x: 0.2, y: 0.05, w: 12.8, h: 0.6, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
const pearls = [
"1. Trendelenburg = SFJ incompetence; Perthes = deep vein patency before surgery",
"2. GSV terminates 3.5 cm below + lateral to pubic tubercle (SFJ) – NOT at pubic tubercle itself",
"3. Cockett perforators at 6, 13.5, 18 cm from heel → ulcer in gaiter area",
"4. Femoral vein (SFV) = DEEP VEIN – common exam trap!",
"5. CEAP C6 = active ulcer; C4b = lipodermatosclerosis (most advanced without ulcer)",
"6. Duplex: reflux >0.5 sec (superficial) and >1 sec (deep) = significant",
"7. ABPI <0.8 → do NOT apply compression stockings (PAD present)",
"8. ABPI >1.3 → non-compressible calcified vessels (DM/ESRD) → toe pressure needed",
"9. Buerger = young male + smoker + upper+lower limb + corkscrew collaterals",
"10. Saphenous nerve at risk in lower 2/3 of GSV stripping (strip only to knee)",
"11. Dorsalis pedis = lateral to EHL tendon on dorsum of foot; absent in 10–15%",
"12. EVLA/RFA = NICE first-line (UK); Traditional surgery = standard in Nepal",
"13. Saphena varix = cough impulse at groin ← DO NOT confuse with femoral hernia",
"14. Stop smoking = ONLY treatment that alters natural history in Buerger's disease",
];
const col1 = pearls.slice(0, 7);
const col2 = pearls.slice(7);
s.addText(col1.map((p, i) => ({ text: p, options: { bullet: { code: "2713", color: C.amber }, fontSize: 13, color: C.white, breakLine: i < col1.length - 1, paraSpaceBefore: 5, fontFace: "Calibri" } })),
{ x: 0.3, y: 0.85, w: 6.2, h: 6.3, valign: "top" });
s.addShape(pres.ShapeType.rect, { x: 6.55, y: 0.85, w: 0.05, h: 6.3, fill: { color: C.amber }, line: { color: C.amber } });
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{ x: 6.7, y: 0.85, w: 6.3, h: 6.3, valign: "top" });
}
// ── FINAL SLIDE ───────────────────────────────────────────────────
{
const s = pres.addSlide();
s.background = { color: C.navy };
s.addShape(pres.ShapeType.rect, { x: 0, y: 5.5, w: 13.3, h: 2.0, fill: { color: C.teal }, line: { color: C.teal } });
s.addShape(pres.ShapeType.rect, { x: 0, y: 5.5, w: 2.5, h: 2.0, fill: { color: C.blue }, line: { color: C.blue } });
s.addText("THANK YOU", { x: 0.4, y: 1.5, w: 12.5, h: 1.5, fontSize: 52, bold: true, color: C.white, fontFace: "Calibri", align: "center", charSpacing: 8 });
s.addText("Good luck in your Final MBBS Surgery Examination!", { x: 0.4, y: 3.2, w: 12.5, h: 0.7, fontSize: 22, color: C.amber, fontFace: "Calibri", align: "center" });
s.addText("Sources: Bailey & Love's Short Practice of Surgery 28e | Sabiston Textbook of Surgery 21e\nSchwartz's Principles of Surgery 11e | SRB Manual of Surgery | NICE NG23",
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// ── WRITE FILE ────────────────────────────────────────────────────
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Running Command
cd /home/daytona/workspace/varicose-vein-pptx && node build.js 2>&1
Editing File
~/varicose-vein-pptx/build.js
Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/varicose-vein-pptx/build.js'
Running Command
cd /home/daytona/workspace/varicose-vein-pptx && node build.js 2>&1
Seriously what happen to you
Running Command
ls /home/daytona/workspace/varicose-vein-pptx/
Writing File
~/varicose-vein-pptx/build.js
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// ═══════════════════════════════════════════
// SLIDE 1 – TITLE
// ═══════════════════════════════════════════
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// ═══════════════════════════════════════════
// SLIDE 2 – TOPIC INDEX
// ═══════════════════════════════════════════
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const L = ["1. Short History","2. Inspection Findings","3. Perforator Names","4. Course of Great Saphenous Vein","5. CEAP Classification","6. Trendelenburg Test","7. Other Clinical Tests","8. VV vs DVT","9. VV vs Hemangioma","10. Deep Venous System","11. Duplex Scan","12. Duplex Use in VV","13. ABPI Grading"];
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// ═══════════════════════════════════════════
// Q1 – HISTORY
// ═══════════════════════════════════════════
secHead("1","Short History – Varicose Vein","Bailey & Love 28e, Ch 62");
cSlide("Q1: Short History – Key Points to Cover",[
{h:"Presenting Complaint"},
"Prominent tortuous veins – medial leg / posterior calf",
"Aching, heaviness, throbbing, burning – worse end of day / prolonged standing",
"Relief: elevation, compression stockings",
"Swelling ankle, itching, skin discolouration",
{h:"Duration & Laterality"},
"When first noticed | Which limb first | Bilateral?",
"Sudden painful episode? → Superficial vein thrombosis (SVT)",
{h:"Risk Factors (Mnemonic: PODS FP)"},
{s:"Parity / Pregnancy – hormonal + mechanical compression of IVC"},
{s:"Occupation – prolonged standing (teacher, surgeon, nurses)"},
{s:"DVT history – secondary (post-thrombotic) varicosities"},
{s:"Surgery / trauma to limb"},
{s:"Family history – autosomal dominant tendency"},
{s:"Previous treatment / recurrence"},
{h:"Complications Enquiry"},
"Bleeding (spontaneous or traumatic) | Ulceration | Eczema | Thrombophlebitis",
],"Bailey & Love 28e, Ch 62");
// ═══════════════════════════════════════════
// Q2 – INSPECTION
// ═══════════════════════════════════════════
secHead("2","Inspection Findings","Standing patient");
cSlide2("Q2: Inspection Findings – Patient Standing",[
{h:"General"},
"Patient must stand – veins collapse when supine",
"Note BMI, limb symmetry, ankle oedema",
{h:"Varicosities"},
"Medial thigh/calf → GSV system incompetence",
"Posterolateral calf → SSV system",
"Anterolateral thigh/calf → Accessory anterior GSV",
{h:"Saphena Varix"},
"Grape-like lump at groin (SFJ), disappears lying down",
"Impulse on cough; DO NOT confuse with femoral hernia",
{h:"Skin Changes (CEAP C4–C6)"},
{s:"Varicose eczema (C4a) – erythema, scaling, weeping"},
{s:"Haemosiderin pigmentation – brownish discolouration medial ankle"},
{s:"Lipodermatosclerosis C4b – woody induration, 'inverted champagne bottle'"},
{s:"Atrophie blanche – white sclerotic plaques"},
{s:"Corona phlebectatica C4c – fan of intradermal veins at ankle"},
{s:"Active venous ulcer C6 – shallow, sloping, medial gaiter area"},
],
"Venous drainage of lower limb\n(Sabiston 21e, Fig 108.2)",
"Bailey & Love 28e, Ch 62");
// ═══════════════════════════════════════════
// Q3 – PERFORATORS
// ═══════════════════════════════════════════
secHead("3","Named Perforator Veins","Sabiston 21e, Ch 108");
cSlide2("Q3: Named Perforating Veins of Lower Limb",[
{h:"Definition"},
"Connect superficial ↔ deep system through deep fascia",
"Normally valves allow superficial→deep direction only",
"Incompetent perforators: deep→superficial reflux → venous hypertension",
{h:"Named Perforators (Viva High-Yield)"},
{s:"Dodd / Hunterian: mid-thigh, GSV ↔ femoral vein"},
{s:"Boyd: below knee medial (tibial), GSV ↔ popliteal/posterior tibial"},
{s:"Cockett I: 6 cm from heel (medial ankle)"},
{s:"Cockett II: 13.5 cm from heel"},
{s:"Cockett III: 18 cm from heel"},
{s:"May/Kuster (Paratibial): medial leg, multiple levels"},
{s:"Bassi: medial foot / instep"},
{h:"Clinical Significance"},
"Cockett perforators → venous ulcer at medial gaiter area",
"Incompetent perforators identified: >3.5 mm diameter + reflux on duplex",
{k:"Must ligate Cockett perforators in venous ulcer surgery"},
],
"Perforating veins of lower limb\n(Sabiston 21e, Fig 108.3)\n\nCockett perforators at\n6, 13.5, 18 cm from heel",
"Sabiston 21e, Ch 108");
// ═══════════════════════════════════════════
// Q4 – GSV COURSE
// ═══════════════════════════════════════════
secHead("4","Course of the Great Saphenous Vein (GSV)","Bailey & Love 28e | Sabiston 21e");
cSlide("Q4: Course of the Great Saphenous Vein",[
{h:"Origin"},
"Dorsal venous arch → medial end of 1st metatarsophalangeal joint",
{h:"Course – Medial Aspect of Lower Limb"},
{s:"Passes ANTERIOR to medial malleolus"},
{s:"Ascends posteromedially along the leg"},
{s:"Passes POSTERIOR to medial femoral condyle (knee)"},
{s:"Ascends anteromedially in the thigh"},
{s:"Passes through saphenous opening (cribriform fascia) in femoral triangle"},
{s:"Joins common femoral vein at SFJ – 3.5 cm below & lateral to pubic tubercle"},
{h:"Tributaries at SFJ (Mnemonic: SELF HELP)"},
{s:"S – Superficial Epigastric"},
{s:"E – External Pudendal (superficial)"},
{s:"L – Lateral cutaneous (superficial circumflex iliac)"},
{s:"F – Femoral (deep external pudendal)"},
{s:"H – Hunterian perforator (mid-thigh)"},
{h:"Nerve Relations"},
{k:"Saphenous nerve: accompanies GSV in lower 2/3 of leg → RISK in stripping"},
"Strip GSV only to KNEE, NOT ankle, to protect saphenous nerve",
],"Bailey & Love 28e, Ch 62 | Sabiston 21e");
// ═══════════════════════════════════════════
// Q5 – CEAP
// ═══════════════════════════════════════════
secHead("5","CEAP Classification","Sabiston 21e | Bailey & Love 28e");
tblSlide("Q5: CEAP – Clinical Classification (C Component)",
["Class","Description","Signs / Notes"],
[
["C0","No visible / palpable venous disease","Symptoms only"],
["C1","Telangiectasia or reticular veins","Spider veins <3 mm; cosmetic"],
["C2","Varicose veins","Dilated tortuous veins ≥3 mm"],
["C2r","Recurrent varicose veins","Post-treatment recurrence (2020 update)"],
["C3","Oedema","Ankle/leg oedema; no skin changes"],
["C4a","Pigmentation + Eczema","Haemosiderin; varicose eczema"],
["C4b","Lipodermatosclerosis (LDS)","Woody induration; atrophie blanche"],
["C4c","Corona phlebectatica","Fan of intradermal veins at ankle (2020 update)"],
["C5","Healed venous ulcer","Scar at previous ulcer site"],
["C6","Active venous ulcer","Open venous ulcer – medial gaiter area"],
["C6r","Recurrent active ulcer","Recurrent open ulcer (2020 update)"],
],
[1.4,4.0,7.2],
"Sabiston 21e, Ch 108 | 2020 CEAP Update"
);
cSlide("Q5: CEAP – E, A, P Components & Example",[
{h:"E – Etiologic Classification"},
{s:"Ec = Congenital | Ep = Primary (no known cause)"},
{s:"Es = Secondary (post-thrombotic DVT) | En = No cause identified"},
{h:"A – Anatomic Classification"},
{s:"As = Superficial | Ap = Perforator | Ad = Deep | An = None"},
{h:"P – Pathophysiologic Classification"},
{s:"Pr = Reflux | Po = Obstruction | Pr,o = Both | Pn = None"},
{h:"Suffix: Symptomatic vs Asymptomatic"},
{s:"Add 'S' for symptomatic, 'A' for asymptomatic: e.g. C2S, C3A"},
{h:"Typical Varicose Vein Patient Example"},
{k:"C2S, Ep, As, Pr = Symptomatic varicose vein, primary, superficial reflux"},
{h:"Venous Severity Scoring (Additional)"},
"Venous Clinical Severity Score (VCSS) – tracks treatment outcomes",
"Venous Segmental Disease Score (VSDS) – anatomical severity",
],"Sabiston 21e, Ch 108");
// ═══════════════════════════════════════════
// Q6 – TRENDELENBURG
// ═══════════════════════════════════════════
secHead("6","Trendelenburg Test","Bailey & Love 28e | SRB Manual");
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bar(s,"Q6: Trendelenburg Test – Steps & Interpretation");
// Step boxes
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{n:"2",t:"Apply Tourniquet at SFJ",d:"Compress GSV at\ngroin (SFJ level)"},
{n:"3",t:"Patient Stands",d:"Observe venous filling\nfrom below tourniquet"},
{n:"4",t:"Release Tourniquet",d:"Observe sudden\nfilling from above"},
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// Results
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{bg:C.amber+"33",bc:C.amber,t:"UNCONTROLLED +ve (Part II)",d:"Veins still fill slowly WITH tourniquet\n→ Incompetent perforators BELOW\n→ Multiple level incompetence"},
{bg:C.red+"33",bc:C.red,t:"RELEASE +ve (Part III)",d:"Sudden fill from ABOVE on release\n→ Clinically most significant\n→ Confirms SFJ reflux\n→ Indicates need for SFJ ligation"},
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s.addText("Modern practice: Tourniquet tests largely REPLACED by Duplex Ultrasound (Bailey & Love 28e, Ch 62)",
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// ═══════════════════════════════════════════
// Q7 – OTHER TESTS
// ═══════════════════════════════════════════
secHead("7","Other Clinical Tests","Bailey & Love 28e | SRB Manual");
cSlide("Q7: Other Clinical Tests in Varicose Vein",[
{h:"1. Multiple Tourniquet Test (Modified Trendelenburg)"},
"Apply tourniquet sequentially at: upper thigh → above knee → below knee",
"Locates level of incompetent perforators more precisely",
{h:"2. Perthes Test (Deep Vein Patency)"},
{s:"Tourniquet at mid-thigh while patient STANDS (veins distended)"},
{s:"Patient walks / exercises on toes ×10"},
{s:"Veins EMPTY → deep veins patent + perforators competent → SAFE to operate"},
{s:"Veins ENGORGE + pain → deep veins blocked (DVT) → DO NOT OPERATE"},
{h:"3. Schwartz / Tap Test"},
"Tap one varix; feel transmitted impulse at another → confirms varicose column continuity",
{h:"4. Fegan's Test (Perforator Mapping)"},
{s:"Leg elevated to empty veins; mark fascial defects (perforators) with finger pressure"},
{s:"Patient stands: bulge + impulse at defects confirms incompetent perforators"},
{h:"5. Morrissey's Cough Impulse"},
"Finger at SFJ (groin); cough impulse suggests SFJ incompetence or saphena varix",
{h:"6. Hand-held Doppler (Bedside)"},
"Probe over SFJ; Valsalva/calf squeeze → reversed flow = reflux confirmed",
{k:"Duplex Ultrasound has replaced all bedside tests in modern practice"},
],"Bailey & Love 28e, Ch 62");
// ═══════════════════════════════════════════
// Q8 – VV vs DVT
// ═══════════════════════════════════════════
secHead("8","Varicose Vein vs DVT","Differential Diagnosis");
twoCol("Q8: Differentiate Varicose Vein from DVT",
[
{h:"VARICOSE VEIN"},
"Gradual onset, long history",
"Dilated, tortuous, superficial visible veins",
"Medial leg / posterior calf distribution",
"Prominent on standing; collapses lying down",
"Non-tender or mildly tender",
"Skin: eczema, pigmentation, LDS, ulcer",
"No acute limb swelling (unless SVT)",
"Afebrile, no systemic features",
"ABPI: Normal",
"D-dimer: Normal",
{k:"Duplex: Superficial reflux; deep veins patent"},
],
[
{h:"DVT (Deep Vein Thrombosis)"},
"Acute onset; precipitating event (surgery, bed rest, malignancy, OCP)",
"Limb swollen, tense, heavy",
"Calf pain + pitting oedema",
"Erythema, warmth, dilatation of superficial veins (secondary)",
"Calf tenderness on palpation",
"Homan's sign (unreliable): calf pain on dorsiflexion",
"Iliofemoral DVT: oedema to thigh, Phlegmasia cerulea dolens",
"Wells Score pre-test probability",
"D-dimer: Elevated (sensitive, non-specific)",
{k:"GOLD STANDARD: Duplex – non-compressibility of vein"},
],
"VARICOSE VEIN","DVT",
"Bailey & Love 28e | Sabiston 21e"
);
// ═══════════════════════════════════════════
// Q9 – VV vs Hemangioma
// ═══════════════════════════════════════════
secHead("9","Varicose Vein vs Hemangioma","Differential Diagnosis");
twoCol("Q9: Differentiate Varicose Vein from Hemangioma / Venous Malformation",
[
{h:"VARICOSE VEIN"},
"Adults; increases with age",
"Along GSV or SSV territory (medial/posterior leg)",
"Tortuous, linear, knot-like dilated veins",
"Compressible; refills from above on release",
"Empties on elevation; prominent on standing",
"Cough impulse at SFJ if SFJ incompetent",
"No birthmark / cutaneous port-wine stain",
"No bruit",
"Duplex: reflux in superficial system",
{k:"Definite anatomical territory of GSV/SSV"},
],
[
{h:"HEMANGIOMA / VENOUS MALFORMATION"},
"Present since birth / childhood (congenital)",
"Any distribution; often diffuse or segmental",
"Bluish-purple spongy / soft mass",
"Compressible; fills slowly on release",
"Present in ALL positions (not postural)",
"May transilluminate",
"Bruit/thrill if AV malformation component",
"Associated port-wine stain (KTS)",
"MRI: gold standard – flow voids, enhancement",
{k:"Klippel-Trenaunay: VM + port-wine stain + limb hypertrophy"},
],
"VARICOSE VEIN","HEMANGIOMA / VM",
"Bailey & Love 28e"
);
// ═══════════════════════════════════════════
// Q10 – DEEP VENOUS SYSTEM
// ═══════════════════════════════════════════
secHead("10","Deep Venous System","Sabiston 21e, Ch 108");
cSlide2("Q10: Deep Venous System of Lower Limb",[
{h:"From Foot → IVC (distal to proximal)"},
{s:"Anterior tibial veins → dorsum of foot + anterior compartment"},
{s:"Posterior tibial veins → medial plantar + calf muscles"},
{s:"Peroneal (fibular) veins → lateral compartment"},
{s:"All three join → POPLITEAL VEIN (behind knee)"},
{s:"Popliteal V → adductor canal → FEMORAL VEIN (SFV)"},
{s:"SFV + Profunda femoris vein → COMMON FEMORAL VEIN (CFV)"},
{s:"CFV crosses inguinal ligament → EXTERNAL ILIAC VEIN"},
{s:"External iliac + Internal iliac → COMMON ILIAC VEIN"},
{s:"R+L common iliac → INFERIOR VENA CAVA (IVC, L5 level)"},
{h:"Common Viva Trap"},
{k:"Femoral (Superficial Femoral) Vein = DEEP VEIN"},
"It is NOT superficial despite the name – a common clinical error",
{h:"Venous Valves"},
"Most numerous distally (tibial level); absent in IVC",
"Bicuspid valves prevent retrograde flow",
"Valve failure → reflux → venous hypertension → varicosities",
],
"Deep venous system\n(Sabiston 21e, Fig 108.2)\n\nNote: popliteal → femoral\n→ external iliac → IVC",
"Sabiston 21e, Ch 108");
// ═══════════════════════════════════════════
// Q11 & 12 – DUPLEX
// ═══════════════════════════════════════════
secHead("11-12","Duplex Ultrasound Scan","Bailey & Love 28e, Ch 62");
cSlide("Q11: What is a Duplex Scan?",[
{h:"Two Components"},
{s:"B-Mode (greyscale): anatomy, thrombus, compressibility of vein"},
{s:"Doppler (colour/pulsed-wave): direction of flow, velocity, reflux"},
{h:"Technique"},
"High-frequency linear transducer: 7.5–13 MHz",
"Blue = antegrade flow (toward heart); Red = retrograde (reflux)",
"Augment flow: calf compression or Valsalva manoeuvre then release",
{h:"How to Detect Reflux"},
"Apply Valsalva or calf squeeze, then release",
{s:"Superficial veins: reflux >0.5 sec = significant"},
{s:"Deep veins (popliteal/femoral): reflux >1.0 sec = significant"},
{h:"DVT Detection (Gold Standard)"},
"Non-compressibility of vein under probe = DVT",
"Absence of colour flow; intraluminal echogenicity",
"Sensitivity 95%, Specificity 98% for proximal DVT",
{k:"Duplex is gold standard for varicose veins AND DVT"},
],"Bailey & Love 28e, Ch 62");
cSlide("Q12: Use of Duplex Scan in Varicose Vein",[
{h:"1. Pre-operative Assessment (MANDATORY before intervention)"},
{s:"Confirm deep venous patency (equivalent of Perthes test)"},
{s:"Locate exact site of SFJ / SPJ incompetence"},
{s:"Map extent of GSV / SSV / accessory saphenous reflux"},
{s:"Identify incompetent perforators (>3.5 mm + reflux)"},
{s:"Mark SSV and SPJ on skin (variable anatomy – critical for surgery)"},
{s:"Detect unsuspected DVT"},
{h:"2. Intra-operative"},
"Duplex-guided cannulation for EVLA / RFA catheter placement",
"Confirm perivenous tumescent anaesthetic halo (Bailey & Love Fig 62.17)",
"Confirm vein closure immediately post-ablation",
{h:"3. Post-operative Follow-up"},
"Confirm successful ablation at 6 weeks",
"Detect EHIT (Endovenous Heat-Induced Thrombosis) at SFJ/SPJ",
{k:"NICE NG23: Duplex imaging for ALL patients before any treatment"},
],"Bailey & Love 28e, Ch 62 | NICE NG23");
// ═══════════════════════════════════════════
// Q13 – ABPI
// ═══════════════════════════════════════════
secHead("13","ABPI Grading","Peripheral Arterial Assessment");
tblSlide("Q13: ABPI – Grading and Clinical Interpretation",
["ABPI Value","Interpretation","Clinical Action"],
[
[">1.3","Non-compressible vessels (calcification – DM/ESRD)","Toe pressure / duplex / MRI needed"],
["1.0 – 1.3","Normal","No PAD; full compression safe"],
["0.8 – 1.0","Borderline / Mild PAD","Cautious compression; monitor"],
["0.5 – 0.8","Moderate PAD","Reduced compression only; vascular review"],
["0.3 – 0.5","Severe PAD","No compression; urgent vascular referral"],
["< 0.3","Critical Limb Ischaemia (CLI)","Emergency vascular surgery"],
],
[2.3,4.5,5.8],
"Bailey & Love 28e | TASC II Guidelines"
);
cSlide("Q13: How to Calculate ABPI – Technique",[
{h:"Measurement Steps"},
"Patient supine; rest for 10 minutes",
"Measure brachial systolic BP – both arms; use the HIGHER value",
"Measure ankle systolic BP using Doppler probe:",
{s:"Dorsalis pedis artery AND posterior tibial artery; use HIGHER value"},
{h:"Formula"},
{k:"ABPI = Ankle Systolic BP ÷ Brachial Systolic BP"},
{h:"Example Calculation"},
{s:"Ankle BP = 80 mmHg | Brachial BP = 120 mmHg"},
{s:"ABPI = 80 ÷ 120 = 0.67 → Moderate PAD"},
{h:"Clinical Relevance in Varicose Vein"},
"Mixed arterio-venous disease (PAD + CVI) is common, especially elderly/diabetic",
"Compression bandaging CONTRAINDICATED if ABPI < 0.8",
"ALWAYS measure ABPI before prescribing compression in elderly or diabetic patients",
{k:"ABPI <0.5 → urgent vascular referral regardless of venous disease"},
],"Bailey & Love 28e");
// ═══════════════════════════════════════════
// Q14 – CLI
// ═══════════════════════════════════════════
secHead("14","Critical Limb Ischaemia (CLI)","Bailey & Love 28e | TASC II");
cSlide("Q14: Critical Limb Ischaemia – Definition, Features & Fontaine",[
{h:"Definition (TASC II)"},
"Chronic ischaemic REST PAIN for >2 weeks, AND/OR",
"Arterial ulceration or gangrene of foot/toes",
"With confirmed haemodynamic compromise: ABPI <0.4 or Ankle pressure <50 mmHg",
{h:"Symptoms & Signs"},
{s:"Rest pain: burning/aching forefoot; WORSE at night; patient hangs leg down for relief"},
{s:"Buerger's angle <20°: foot turns pale/white on elevation (gravity-dependent flow)"},
{s:"Buerger's reactive hyperaemia: dependent rubor (red/purple) on lowering leg"},
{s:"Trophic changes: shiny skin, hair loss, thickened nails, muscle wasting"},
{s:"Arterial ulcer: punched-out, PAINFUL, on toes/pressure points/heel"},
{s:"Dry/wet gangrene of toes"},
{h:"Fontaine Classification"},
{s:"I: Asymptomatic"},
{s:"II: Claudication (IIa >200 m | IIb <200 m)"},
{s:"III: Rest pain → CLI begins here"},
{s:"IV: Tissue loss / Gangrene → CLI"},
{k:"Fontaine III and IV = Critical Limb Ischaemia"},
],"Bailey & Love 28e, Ch 53 | TASC II");
// ═══════════════════════════════════════════
// Q15 – BUERGER vs ATHEROSCLEROSIS
// ═══════════════════════════════════════════
secHead("15","Buerger Disease vs Atherosclerosis","Bailey & Love 28e");
twoCol("Q15: Buerger Disease (TAO) vs Atherosclerosis (PAD)",
[
{h:"BUERGER'S DISEASE (TAO)"},
"Age: Young men, 20–40 years",
"Sex: 95% male",
"Smoking: MANDATORY (heavy, usually cigarettes)",
"Vessels: small/medium arteries AND veins",
"Distribution: tibial, radial, ulnar; both upper + lower limbs",
"Bilateral, distal (digits, feet, hands)",
"Migrating superficial thrombophlebitis (hallmark)",
"No conventional atherosclerotic risk factors",
"Pathology: non-atherosclerotic segmental inflammatory thrombus",
"Angiogram: CORKSCREW collaterals; abrupt occlusions; skip lesions",
{k:"ONLY treatment: STOP SMOKING completely"},
],
[
{h:"ATHEROSCLEROSIS (PAD)"},
"Age: Elderly, >50 years",
"Sex: Both; males > females",
"Smoking: Risk factor (not mandatory)",
"Vessels: large/medium arteries (aorta, iliac, SFA, popliteal)",
"Distribution: lower limbs predominantly",
"Proximal involvement (aortoiliac, SFA/popliteal)",
"NO migrating thrombophlebitis",
"Risk factors: DM, HTN, hyperlipidaemia, obesity, smoking",
"Pathology: lipid plaque, calcification, intimal thickening",
"Angiogram: irregular, diffuse, calcified stenoses; SFA occlusion common",
{k:"Treatment: risk factors + antiplatelets + revascularisation"},
],
"BUERGER (TAO)","ATHEROSCLEROSIS (PAD)",
"Bailey & Love 28e, Ch 52 & 53"
);
// ═══════════════════════════════════════════
// Q16 – LOWER LIMB POWER
// ═══════════════════════════════════════════
secHead("16","Assessment of Lower Limb Power","Neurological Examination");
tblSlide("Q16: Lower Limb Power – Myotomes & Muscles",
["Movement","Nerve Root (Myotome)","Muscles Tested"],
[
["Hip Flexion","L1, L2, L3","Iliopsoas"],
["Hip Extension","L5, S1, S2","Gluteus maximus"],
["Hip Abduction","L4, L5, S1","Gluteus medius & minimus"],
["Hip Adduction","L2, L3, L4","Adductors"],
["Knee Extension","L3, L4","Quadriceps femoris"],
["Knee Flexion","L5, S1, S2","Hamstrings (biceps femoris, semitendinosus)"],
["Ankle Dorsiflexion","L4, L5","Tibialis anterior"],
["Ankle Plantarflexion","S1, S2","Gastrocnemius, Soleus"],
["Big Toe Extension","L5","Extensor hallucis longus"],
["Toe Flexion","S1, S2","Flexor digitorum brevis"],
],
[3.8,3.2,5.6],
"Clinical Examination"
);
cSlide("Q16: MRC Grading Scale + Neurogenic vs Vascular Claudication",[
{h:"MRC Power Scale (Grade 0–5)"},
{s:"0 = No contraction"},
{s:"1 = Flicker / visible contraction; no joint movement"},
{s:"2 = Movement WITH gravity eliminated"},
{s:"3 = Movement AGAINST gravity; not against resistance"},
{s:"4 = Movement against gravity + some resistance"},
{s:"5 = Full power against full resistance (NORMAL)"},
{h:"Neurogenic vs Vascular Claudication (High-Yield Viva)"},
{s:"Vascular: pain on walking ONLY; relieved by STANDING STILL"},
{s:"Neurogenic: pain on walking AND standing; relieved by SITTING / LEANING FORWARD (spinal flexion)"},
{s:"Neurogenic: normal ABPI, normal pulses, reduced straight leg raise"},
{h:"Key Spinal Root Signs"},
{s:"L4: weak dorsiflexion, reduced knee jerk"},
{s:"L5: weak big toe extension, no reflex"},
{s:"S1: weak plantarflexion, reduced ankle jerk"},
{k:"Neurogenic claudication → lumbar canal stenosis; ABPI normal"},
],"Bailey & Love 28e | Clinical Examination");
// ═══════════════════════════════════════════
// Q17-20 – PULSES
// ═══════════════════════════════════════════
secHead("17-20","Lower Limb Pulse Palpation","Clinical Examination");
{
const s = pres.addSlide();
s.background = {color:C.offwh};
bar(s,"Q17–20: Palpation of Lower Limb Pulses – Landmarks & Technique");
const pulses = [
{q:"Q17 & Q20",n:"Dorsalis Pedis (DP)",col:C.blue,
lm:"Dorsum of foot between EHL and extensor digitorum longus tendons – LATERAL to EHL tendon at level of 1st inter-metatarsal space",
supply:"Continuation of anterior tibial artery; passes under extensor retinaculum at ankle",
tip:"Absent in 10–15% of normal population (replaced by peroneal perforating branch)"},
{q:"Q18",n:"Posterior Tibial (PT)",col:C.teal,
lm:"Groove behind medial malleolus – midpoint between medial malleolus and posterior border of medial malleolus (ahead of Achilles tendon)",
supply:"Terminal branch of popliteal artery via posterior tibial; gives medial + lateral plantar arteries",
tip:"Press with 2–3 finger pads against underlying tibia; ask patient to relax ankle"},
{q:"Q19",n:"Anterior Tibial (AT)",col:C.lblue,
lm:"Anterior compartment: 2 finger-breadths lateral to anterior tibial border, at ankle level. Rarely palpated clinically – continues as dorsalis pedis",
supply:"Branch of popliteal artery through interosseous membrane; anterior compartment of leg",
tip:"More easily assessed as dorsalis pedis at the ankle"},
{q:"Bonus",n:"Popliteal",col:C.amber,
lm:"Popliteal fossa: knee flexed 30°, thumbs over tibial tuberosity anteriorly, fingers press firmly in midline of popliteal fossa posteriorly",
supply:"Continuation of SFA through adductor hiatus",
tip:"Hard to feel; prominent/expansile pulsation = popliteal aneurysm"},
];
pulses.forEach((p,i)=>{
const col = i<2 ? i*6.6+0.3 : (i-2)*6.6+0.3;
const row = i<2 ? 0.9 : 4.05;
s.addShape(pres.ShapeType.rect,{x:col,y:row,w:6.2,h:2.95, fill:{color:C.white}, line:{color:p.col,pt:2}, rectRadius:0.1});
s.addShape(pres.ShapeType.rect,{x:col,y:row,w:6.2,h:0.45, fill:{color:p.col}, line:{color:p.col}, rectRadius:0.1});
s.addText(`${p.q}: ${p.n}`,{x:col+0.1,y:row,w:6.0,h:0.45, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle"});
s.addText([
{text:"Landmark: ",options:{bold:true,fontSize:12,color:p.col,breakLine:false}},
{text:p.lm,options:{fontSize:12,color:C.dark,breakLine:true}},
{text:"Supply: ",options:{bold:true,fontSize:11,color:C.gray,breakLine:false}},
{text:p.supply,options:{fontSize:11,color:C.dark,breakLine:true}},
{text:"Clinical tip: ",options:{bold:true,fontSize:11,color:C.amber,breakLine:false}},
{text:p.tip,options:{fontSize:11,color:"37474F",breakLine:false}},
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}
// ═══════════════════════════════════════════
// Q21 – ILIAC BRANCHES
// ═══════════════════════════════════════════
secHead("21","Branches of the Iliac Arteries","Anatomy");
{
const s = pres.addSlide();
s.background = {color:C.offwh};
bar(s,"Q21: Branches of the Iliac Arteries");
// Tree diagram
const box = (x,y,w,h,txt,bg,tc,fs=12)=>{
s.addShape(pres.ShapeType.rect,{x,y,w,h,fill:{color:bg},line:{color:bg},rectRadius:0.07});
s.addText(txt,{x,y,w,h,fontSize:fs,bold:true,color:tc,align:"center",fontFace:"Calibri",valign:"middle"});
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box(4.8,0.9,3.8,0.5,"ABDOMINAL AORTA (L4)",C.navy,C.white,12);
line(6.7,1.4,6.7,1.7);
line(3.0,1.7,10.4,1.7);
line(3.0,1.7,3.0,2.0);
line(10.4,1.7,10.4,2.0);
box(1.0,2.0,4.0,0.5,"L. Common Iliac A.",C.blue,C.white,12);
box(8.4,2.0,4.0,0.5,"R. Common Iliac A.",C.blue,C.white,12);
line(3.0,2.5,3.0,2.8); line(1.0,2.8,5.0,2.8);
line(1.0,2.8,1.0,3.1); line(5.0,2.8,5.0,3.1);
line(10.4,2.5,10.4,2.8); line(8.4,2.8,12.4,2.8);
line(8.4,2.8,8.4,3.1); line(12.4,2.8,12.4,3.1);
box(0.1,3.1,2.6,0.5,"Ext. Iliac A.",C.teal,C.white,11);
box(3.2,3.1,3.5,0.5,"Int. Iliac A.\n(Hypogastric)",C.red,C.white,10);
box(7.4,3.1,2.6,0.5,"Ext. Iliac A.",C.teal,C.white,11);
box(10.5,3.1,2.75,0.5,"Int. Iliac A.\n(Hypogastric)",C.red,C.white,10);
s.addText("↓ continues as\nCOMMON FEMORAL A.\n(below inguinal ligament)",{x:0.1,y:3.7,w:2.6,h:0.75,fontSize:11,bold:true,color:C.teal,fontFace:"Calibri",align:"center"});
// Internal iliac branches
s.addText("Internal Iliac Branches (Mnemonic: OILS PUMP)",{x:3.2,y:3.7,w:9.9,h:0.4,fontSize:13,bold:true,color:C.red,fontFace:"Calibri"});
const br = [
"O – Obturator A.","I – Iliolumbar A.","L – Lateral Sacral A.","S – Superior Gluteal A.",
"P – Pudendal (Internal)","U – Uterine A. (female)","M – Middle Rectal A.","P – Perineal A.",
"+ Inferior Gluteal A.","+ Superior/Inferior Vesical A.","+ Umbilical A. (obliterated)"
];
const col1b = br.slice(0,6), col2b = br.slice(6);
s.addText(col1b.map((t,i)=>({text:t,options:{bullet:true,fontSize:12,color:C.dark,breakLine:i<col1b.length-1,fontFace:"Calibri"}})),{x:3.2,y:4.12,w:4.5,h:3.0,valign:"top"});
s.addText(col2b.map((t,i)=>({text:t,options:{bullet:true,fontSize:12,color:C.dark,breakLine:i<col2b.length-1,fontFace:"Calibri"}})),{x:7.8,y:4.12,w:5.0,h:3.0,valign:"top"});
s.addText("Sabiston 21e | Bailey & Love 28e",{x:8.5,y:7.1,w:4.7,h:0.35,fontSize:9,color:C.gray,fontFace:"Calibri",align:"right",italic:true});
}
// ═══════════════════════════════════════════
// Q22 – ARTERIES OF LOWER LIMB
// ═══════════════════════════════════════════
secHead("22","Arteries of the Lower Limb","Complete Course");
{
const s = pres.addSlide();
s.background = {color:C.offwh};
bar(s,"Q22: Arteries of Lower Limb – Complete Course");
const chain = [
{a:"External Iliac A.", b:"→ crosses inguinal ligament → becomes COMMON FEMORAL A."},
{a:"Common Femoral A.", b:"→ gives PROFUNDA FEMORIS (deep femoral) + superficial epigastric, circumflex iliac, ext. pudendal"},
{a:"Superficial Femoral A.", b:"→ descends in adductor canal (Hunter's canal) → exits adductor hiatus"},
{a:"Popliteal A.", b:"→ gives superior + inferior genicular arteries → divides at lower popliteus border"},
{a:"Anterior Tibial A.", b:"→ through interosseous membrane gap → anterior compartment → DORSALIS PEDIS at ankle"},
{a:"Posterior Tibial A.", b:"→ gives PERONEAL (fibular) A. → deep posterior compartment → medial & lateral PLANTAR A. at ankle"},
{a:"Plantar Arch", b:"→ lateral plantar A. anastomoses with dorsalis pedis; gives DIGITAL ARTERIES to toes"},
];
chain.forEach((item,i)=>{
const y = 0.9+i*0.82;
const bg = i%2===0 ? C.navy : C.blue;
s.addShape(pres.ShapeType.rect,{x:0.3,y,w:3.4,h:0.58,fill:{color:bg},line:{color:bg},rectRadius:0.07});
s.addText(item.a,{x:0.3,y,w:3.4,h:0.58,fontSize:12,bold:true,color:C.white,align:"center",fontFace:"Calibri",valign:"middle"});
s.addText(item.b,{x:3.85,y:y+0.02,w:9.2,h:0.58,fontSize:12,color:C.dark,fontFace:"Calibri",valign:"middle"});
if(i<chain.length-1) s.addShape(pres.ShapeType.rect,{x:1.85,y:y+0.58,w:0.06,h:0.24,fill:{color:C.amber},line:{color:C.amber}});
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s.addText("Profunda femoris branches: medial + lateral circumflex femoral + 3 perforating arteries",
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}
// ═══════════════════════════════════════════
// Q23 – INVESTIGATIONS
// ═══════════════════════════════════════════
secHead("23","Investigations","Bailey & Love 28e | Sabiston 21e");
cSlide("Q23: Investigations in Varicose Vein",[
{h:"1. Duplex Ultrasound (GOLD STANDARD – First Line)"},
"Mandatory before ANY intervention (NICE NG23)",
"Maps reflux, deep vein patency, perforators, SPJ anatomy",
{h:"2. ABPI (Ankle Brachial Pressure Index)"},
"Mandatory before prescribing compression",
"Detects co-existent PAD; rules out arterial disease",
{h:"3. Hand-held Doppler (Bedside)"},
"Quick SFJ/SPJ reflux confirmation; limited anatomical detail",
{h:"4. CT Venography / MR Venography"},
"For pelvic/IVC pathology: May-Thurner, pelvic congestion, nutcracker syndrome",
{h:"5. Ascending Phlebography (Venography)"},
"Rarely used now; gold standard for deep venous anatomy if duplex inadequate",
{h:"6. Haematological Investigations (Pre-operative)"},
{s:"FBC, coagulation screen, blood grouping"},
{s:"D-dimer – if DVT suspected"},
{s:"Blood glucose / HbA1c – DM screening"},
{s:"Thrombophilia screen if recurrent DVT / strong family history"},
{k:"Minimum pre-op workup: Duplex + ABPI + routine bloods"},
],"Bailey & Love 28e, Ch 62");
// ═══════════════════════════════════════════
// Q24 – TREATMENT
// ═══════════════════════════════════════════
secHead("24-25","Treatment","Bailey & Love 28e | NICE NG23 | Sabiston 21e");
cSlide("Q24: Treatment of Varicose Vein – Overview",[
{h:"A. Conservative (Non-operative)"},
{s:"Lifestyle: weight loss, avoid prolonged standing, leg elevation >30 cm"},
{s:"Graduated compression stockings (Class I–III); symptomatic relief, not curative"},
{s:"Pharmacotherapy: MPFF (Daflon/Detralex) – reduces symptoms, aids ulcer healing"},
{s:"Wound care for venous ulcer: 4-layer compression bandaging (Charing Cross)"},
{h:"B. Sclerotherapy"},
{s:"Liquid sclerotherapy: sodium tetradecyl sulphate (STS) or polidocanol"},
{s:"Foam sclerotherapy (Tessari method): 1:4 liquid:gas ratio → better mucosal contact"},
{s:"Indications: telangiectasia, reticular veins, small varicosities, post-surgical residuals"},
{h:"C. Thermal Ablation (NICE NG23 FIRST LINE for truncal reflux)"},
{s:"EVLA (Endovenous Laser Ablation): 810–1470 nm laser; energy 60–80 J/cm; ~90–95% success"},
{s:"RFA (Radiofrequency Ablation – ClosureFast™): 120°C cycles; comparable to EVLA"},
{h:"D. Open Surgery (Standard in Nepal)"},
{s:"Flush SFJ ligation + GSV stripping to knee + stab phlebectomy"},
{k:"NICE order: EVLA / RFA → foam sclerotherapy → surgery (if thermal not suitable)"},
],"Bailey & Love 28e, Ch 62 | NICE NG23");
cSlide("Q24: Open Surgery – Trendelenburg (High Tie + Strip)",[
{h:"Indications"},
"GSV reflux with symptomatic varicosities; C2S to C6; failed conservative treatment",
{h:"Steps of Operation"},
{s:"1. Pre-op marking of varicosities with patient STANDING"},
{s:"2. Groin incision: 2 cm below & lateral to pubic tubercle"},
{s:"3. Identify GSV; dissect and divide ALL tributaries at SFJ (SELF group)"},
{s:"4. FLUSH ligation of SFJ – no stump left (prevents neovascularisation)"},
{s:"5. Strip GSV from groin to BELOW KNEE (NOT ankle – saphenous nerve risk)"},
{s:"6. Stab phlebectomy of residual varicosities through 2–3 mm incisions"},
{h:"Complications"},
{s:"Saphenous nerve injury (medial leg numbness) – most common"},
{s:"Sural nerve injury (lateral leg) if SSV stripped"},
{s:"Lymph fistula / lymphocoele at groin"},
{s:"Wound infection, haematoma"},
{s:"Recurrence (~20% at 5 yrs) due to neovascularisation at SFJ"},
{s:"DVT, PE (rare)"},
{k:"Strip GSV only to KNEE to protect saphenous nerve!"},
],"Bailey & Love 28e, Ch 62");
cSlide("Q24: Endovenous Ablation (EVLA & RFA)",[
{h:"EVLA – Endovenous Laser Ablation"},
{s:"Patient: supine; tumescent local anaesthesia + duplex guidance"},
{s:"Laser fibre inserted via percutaneous cannula into GSV"},
{s:"Laser (1470 nm preferred) energy 60–80 J/cm destroys vein wall → fibrosis → occlusion"},
{s:"Perivenous tumescent halo prevents thermal injury to skin/nerves"},
{s:"Success: 90–95% at 2 years; comparable to surgery"},
{h:"RFA – Radiofrequency Ablation (ClosureFast™)"},
{s:"Catheter-mounted coil heated to 120°C; treatment cycles of 20 seconds"},
{s:"Coil withdrawn incrementally (3 cm or 7 cm coil)"},
{s:"Less bruising and pain vs EVLA; both equally effective"},
{h:"Post-procedure Care"},
"Compression stockings for 2 weeks; early ambulation",
"Duplex at 6 weeks to confirm occlusion",
{h:"Complications"},
{s:"EHIT (Endovenous Heat-Induced Thrombosis): thrombus at SFJ → treat with LMWH if Class 2+"},
{s:"Skin burns, paraesthesia, bruising, DVT (rare)"},
{k:"NICE NG23: Thermal ablation is recommended FIRST over surgery"},
],"Bailey & Love 28e, Ch 62");
cSlide("Q25: Treatment at Our Hospital (UCMS/Teaching Hospital, Nepal)",[
{h:"Standard Operative Practice"},
"Most patients: FLUSH SFJ LIGATION + GSV STRIPPING to knee + STAB PHLEBECTOMY",
"Anaesthesia: spinal (most common) or general",
"Setting: day case or short stay (1–2 days)",
{h:"Pre-operative Preparation"},
{s:"Standing vein marking (permanent marker; surgeon does this)"},
{s:"Duplex ultrasound if available – mark SFJ, map varicosities"},
{s:"ABPI measurement; FBC, coagulation, blood glucose, X-match"},
{s:"DVT prophylaxis: LMWH pre-op + TED stockings"},
{s:"Informed consent: recurrence, nerve injury, scar, DVT"},
{h:"Post-operative Care"},
{s:"Crepe bandage → compression stockings at 2 weeks"},
{s:"Elevate limb; early ambulation from day 1"},
{s:"NSAIDs + paracetamol for pain"},
{s:"Review at 2 weeks (wound check) + 6 weeks (clinical review)"},
{h:"Endovenous Availability"},
"EVLA / RFA: available at selected private hospitals (Grande, Norvic, NAMS)",
"Foam sclerotherapy: available for residual/recurrent disease",
{k:"Open surgery = most common practice in Nepal; cost-effective, durable"},
],"Local Practice | Bailey & Love 28e");
// ═══════════════════════════════════════════
// MANAGEMENT FLOWCHART
// ═══════════════════════════════════════════
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s.background = {color:"F7FAFC"};
bar(s,"Management Algorithm – Varicose Vein (UCMS, Nepal)");
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// ═══════════════════════════════════════════
// VIVA PEARLS
// ═══════════════════════════════════════════
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s.addText("VIVA PEARLS – Varicose Vein (TU IOM Examiner Points)",
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"1. Trendelenburg = SFJ incompetence; Perthes = deep vein patency (safe to operate?)",
"2. GSV terminates 3.5 cm below + lateral to pubic tubercle (NOT AT the pubic tubercle)",
"3. Cockett perforators: 6, 13.5, 18 cm from heel → venous ulcer in gaiter area",
"4. Femoral (Superficial Femoral) Vein = DEEP VEIN — common exam trap!",
"5. CEAP C6 = active ulcer; C4b = LDS (most advanced without ulcer)",
"6. Duplex reflux: >0.5 sec (superficial), >1.0 sec (deep) = significant",
"7. ABPI <0.8 → compression CONTRAINDICATED (co-existent PAD)",
];
const col2 = [
"8. ABPI >1.3 → calcified non-compressible vessels (DM) → measure toe pressure",
"9. Buerger = young male + heavy smoker + both limbs + corkscrew collaterals",
"10. Strip GSV only to KNEE (not ankle) → protects saphenous nerve",
"11. Dorsalis pedis: LATERAL to EHL tendon on dorsum of foot; absent 10–15%",
"12. NICE NG23: EVLA/RFA first line (UK); open surgery = standard Nepal practice",
"13. Saphena varix: groin cough impulse → do NOT confuse with femoral hernia",
"14. Buerger disease: STOP SMOKING = only intervention that changes natural history",
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// ═══════════════════════════════════════════
// FINAL SLIDE
// ═══════════════════════════════════════════
{
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s.addShape(pres.ShapeType.rect,{x:0,y:5.6,w:13.3,h:1.9,fill:{color:C.teal},line:{color:C.teal}});
s.addShape(pres.ShapeType.rect,{x:0,y:5.6,w:2.8,h:1.9,fill:{color:C.blue},line:{color:C.blue}});
s.addText("THANK YOU",{x:0.3,y:1.2,w:12.7,h:2.0,fontSize:56,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle",charSpacing:6});
s.addText("Best wishes for your Final MBBS Surgery Examination!",{x:0.3,y:3.5,w:12.7,h:0.7,fontSize:22,color:C.amber,fontFace:"Calibri",align:"center"});
s.addText("Sources: Bailey & Love's Short Practice of Surgery 28e | Sabiston Textbook of Surgery 21e\nSchwartz's Principles of Surgery 11e | SRB Manual of Surgery | NICE NG23",
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}
// ═══════════════════════════════════════════
// WRITE
// ═══════════════════════════════════════════
pres.writeFile({fileName:"/home/daytona/workspace/varicose-vein-pptx/Varicose_Vein_MBBS_Viva_UCMS_TU.pptx"})
.then(()=>console.log("SUCCESS"))
.catch(e=>console.error("ERROR:",e));
Running Command
rm /home/daytona/workspace/varicose-vein-pptx/build.js
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