hi guys good evening good evening good evening can you all see me can you all hear me can we start can we start can we start so I'll be doing a quick recap of all the PQS which are there for last five years uh hi guys good evening good evening right so we'll try to uh keep it to the point i'll not take you know extensive amount of time we'll try to keep it to the point let's see if you're able to answer the questions that are throw across you uh most of them will be you know like you would have heard them before nothing new you know nothing out of the box try to stick to the plan good evening guys good evening right so the question number one in question number one second guys backhand team okay the question number one that you have uh I have a patient with a long-standing non-pitting edema which is present enter in the leg what is the most probable cause okay so talking about a non-pitting edema so first let's quickly look at what are the components that is available for us okay now lymphadeema when it occurs especially if you have chronic lympadeemas they'll present to you as non-pitting correct this is one example arterial one will be pitting edemas coronary artery is also going to be pitting edema whereas when you talk about the Venus disorders in the Venus disorders I can talk about two components one is going to be your varicose veins one is going to be your varicose veins another one is going to be deep thrombosis varicose veins initially when it causes edema that is going to be because of lymphatic blockage here it is going to be in the form of pitting edema dvt will have a nonpitting edema they'll have non-pitting edema right so now the question is which of the following patient with a long-standing pitting edma what is the most probable now out of DV and lymph edma which is more common as all of you have given you right answer here it is going to be A4 MBA okay so precisely looking at the options how do you come to a conclusive one okay so this is with respect to lympadeema now going on the second question i have a 50-year-old male patient who is a chronic smoker okay presence of the hospital with intermittent claudication i have my Q point here the pain is present in both the thighs and the buttock region on walking about 50 500 m what is the likely diagnosis so he's basically asking you based upon the level of occlusion can you predict we can very well predict it right for example if this is the iota this is the iota junction these are common iliac this is the internal this happens to be the external iliac correct now I'm going to tell you based upon the level of occlusion where will the patient have pain that is going to be present right so I can say that three levels of occlusion that we'll talk about number one is at the iottoia occlusion number two it is going to be your occlusion and the last one that we're going to talk about is going to be your femoral occlusion which is going to be here so I've written three different sides of occlusion which is here now if a patient is having an iottoiac occlusion this is what we call it as the iotto occlusion in the iottoiac occlusion the blood flow to both the vessels are going to be decreased so hence it will have a bilateral intermittent claication now obviously it is going to be not allowing the blood to flow below this point so here it will involve the glutius muscle it will involve the thigh muscle it is going to involve the glutius muscle it is going to involve the thigh muscles and this is also going to involve the calf muscles okay so if the level of occlusion is going to be at the iotoiliac correct if there is going to be an iC occlusion if there is going to be an iC occlusion it will be associated with uniateral intermittent claication there'll be glutial sparing so here it is going to be the thigh and the calf intermittent claication it'll be thigh and calf glutial sparing is there if it is going to be femoral this is your femoral occlusion it is a femoral occlusion if there is a femoral occlusion it will have a unilateral intermittent claication involving only the calf muscle right now I have the answer to my question if the patient is having a bilateral intermittent cladication involving glutius and thigh the answer is going to be iottoia occlusion okay so in this context here the patient is presented with intermittent colonication in both the thighs so here bilateral thighs are involved and bilateral glutius muscle that is buttocks are involved so what is the site the arteria the arterial disease involving the superficial femoral no the art involving the iottoiac looks the most likely answer it is not venus insufficiency it is not profendoras so answer here as rightly said is B for Bombay correct p what should be considered there won't be ABI index okay uh right so it is always to the stump site to the brachial artery lit syndrome is seen in bilateral as somebody is asking so where do you see larit syndrome remember if the patient is male in male patients the internal iliacs are going to supply to the gonads the blood supply to the internal are going to be sacrificed so here it is in males there will be bilateral intermittent claudication with male impotency this is what we call it as the layer syndrome this is what we call it as the layer syndrome correct so this is specific for that of our male patients see answer is B for Bombay going to the next question i have a 50-year-old male patient his routine annual checkup he has come found to have an abdominal iotic aneurysm measuring 40 mm in diameter okay on ultrasound which of the following is true about the management of this patient now here is the patient symptotomatic or asymptomatic the question says it is asymptomatic so for management of abdominal iotic aneurysm what is the algorithm that we follow now in a management of abdominal iotic aneurysm okay the first question is whether the patient is symptomatic or symptotomatic whether the patient is symptomatic or whether the patient is a symptotomatic now if the patient is symptomatic irrespective of the size of the aneurysm I am going to advise for repair this is what we've been telling you in an asymptomatic I would look for something called as the critical diameter of the aneurysm now the critical diameter of the abdominal iotic aneurysm is 5.5 cm so we will see whatever the aneurysm is presented is the sax diameter if the andurism sacks diameter is less than critical diameter or if the andismal sacks diameter is more than that of critical diameter correct now if the diameter of the sack which is present is less than the critical diameter then it is going to be observation and followup this is going to be observation and followup on the other hand if the diameter sack is more than the critical diameter then you have to go ahead with repair right in the observation and followup in the observation and followup you have to see what is the presenting diameter also right if it is less than 4 cm or more than 4 cm less than 4 cm you'll ask the patient to follow up in 6 months more than 4 cm you'll ask to follow up in less than sorry less than 4 cm 1 year more than 4 cm you follow up in 6 months okay correct but 5.5 cm is the critical diameter do not goof up on that now here it says which of the following is true about this do we require an urgent endovvascular it is asymptomatic 4 cm that means less than 5.5 it is not in the critical diameter surgery is indicated and diameter is more than 55 it is correct urgent peel the patient OT no requirement surgery indicated only no it is 55 that is 5.5 answer here is B for Bombay is that clear is that clear yes a male female 5 mm is the component that you can vary out but if they have not mentioned in that context of it you can take it 5.5 cm a single important data clear sir going to the next question i have a 70 year old female presence with pain in the thigh during walking investigation reveals the finding given below which of the following is the best surgical management for this okay now if you look at this I think you're very well able to identify this is the iota these are the iliacs that is going to be common from here it go internal and external so here it is the iliac occlusion that you're going to see okay now as you can see there's no flow here the iliac flow is not there it's an iliac occlusion so iottomoral bypass ioto femoral bypass would be the best one in this particular scenario so the patient is 70 years old the patient is going to be 70 years old the investigation is here so based upon the occlusion where do you do the bypass i'll quickly show you the bypasses also now imagine if this is the iota that you have based upon the site of occlusion you will decide that where do you need to do the bypass so let's say these are the sides these are the internal this is the external then into common femoral and then to the opl artery okay let's say this is the given component that you have now based upon the site of occlusion let's say the site of occlusion is here that is at the iottoc for an iotoiac the bypass will be iotto bifmoral bypass this will be your ioto bif femoral it is an ioto bif femoral bypass okay now if the occlusion is found to be at this particular site that is at the one then it is going to be an iottomoral bypass see if it is here then it is going to be your iotto it is an ioto femoral bypass if it is present at the femoral artery then it is going to be an ilopolitial bypass this is going to be your iOpass this is going to be an iio poplial bypass okay so these are the sides of bypasses that you're going to create if at all they want to ask in the exam they'll ask you what is the material used for these two bypasses we will use dacrine and if it comes to iO bypass what is the material that you're going to use you're going to use an autologus great safness vein your autologus great suffness vein or you can use a poly tetraoethylene graft PTFE that is a polyetraoethylene graft can be used okay so here because we're talking about the iliac occlusion I would go with iottomoral bypass so iottomoral bypass is present as option number C iopmoremoral iottomoral it is an iottomoral if the occlusion is present at the iota I will do an ioto bifmoral bypass if occlusion is present only in the eye then do iotto femoral bypass if it is femoral at then do an iOpass okay clear so this is based upon the level of occlusion you have to decide it this has been a repeat exam question you cannot go to the exam without knowing your bypasses okay so etherosclerosis bypasses plays a very very very very important role is that clear got it okay moving on to the next one i have a young man presented to the outpatient department with dilated veins on the left leg according to the SE classification of varicose vein what will be the C stage of this patient now you can see the image which is very well given to you you can see there are dilated veins which are present here you can see the dilated veins which are present here not very evident evident per se okay now if you look at the entire context of it right we'll try to understand the C classification I hope everybody knows it okay a quick recap of the C classification on the status of this C 0 indicates there is no evidence of Venus disease okay T1 there is Telangasia there is telenactia or reticular ular vein telling this is thin threadlike veins where it is less than 1 mm in diameter they'll be less than 1 mm in diameter reticular vein is going to be 1 to 3 mm in diameter if it becomes greater than that it will be called as C2 c2 is nothing but your varicose vein varicose vein if it is more than 3 mm in diameter t3 there'll be presence of edema around the ankle t4 A there will be presence of pigmentation t4b it will be lipodermatosclerosis it is lipodermatosis t4 C is your coronctica it is your coronoctatica t5 is your healed Venus ulcer it is your healed Venus ulcer t6 is going to be your active Venus also it is going to be an active Venus also okay now the question is if you see in this right if you're able to see these indicated veins see these thin threadlike veins are going to be telling it tastes slightly more bigger is reticular but such an evident vein is going to be a varicose vein okay so I know it is going to be your varicose vein so if it is a varicose vein you have to see whether it is C2A or C2S now it is the anatomical location what is C2A what is C2S it cannot be C1 Because C1 is telling it is a reticular vein c4 A is going to be pigmentation i cannot see pigmentation any pigmentation is usually seen around the level of ankle clear now my question to you is is it C2A or is it C2S is it C2A or C2S quick feedback quick feedback wait I am accessing that okay very good c2a is asytomatic and C2S is symptotomatic so when we say C2A C2A is varicose vein which is asytomatic and C2S where it is symptotomatic now why this becomes important is there's something called as C2R also C2R basically means recurrent varicose vein this indicates recurrent varicose vein and there's something called a C6R that is your recurrent venus ulcer this is your recurrent venus ulcers do not forget about these okay okay now here the patient is presented to you without patient with dilated veins on the left there is no pain no other symptoms it is just the dilated veins okay so in that context will you call it a symptomatic or asytomatic patient is presented with dilated veins on the leg there is no complaints of pain there is no complaint of anything it is a symptotomatic or symptotomatic this is where the basic component lies across so this is asytomatic dilated veins does not count as symptoms they're just a finding correct absolutely correct answer is going to be A for ADAB cleassification is very very important this should be on the tips of your finger they can ask you what causes pigmentation in varicose vein what causes pigmentation the pigmentation is because of lipodermatoscler sorry pigmentation occurs and causes lipodermatosclerosis but pigmentation is because of hemosidosis what is hemocidrosis pigmentation is basically because of hemocidrosis it is because of hemocidrosis what is heis it is heidarin plus melanin of the skin hemosis is nothing but hemocetin with melanin of the skin is what we call it as pigmentation absolutely correct okay going on to the next question what do you have the next question which is going to be present okay a construction worker came to the OPD complaining about white fingers has been working in cement and concrete industry has been working on heavy machinery drills woods and furnishing points for 20 years which is most likely aology of this condition what do you think it is is it because of the candidial infection of the finger exposure to the water exposure to the thinners and the paints is it continuous exposure to the cements or the concrete or exposure drills and machines so here the patient is in the context so it's OPD complaining about white fingers which has been working in cement and concrete see heavy machinery is there what is the most likely condition quick feedback quick feedback absolutely correct it is because of vibrations that is continuous drills and machinery okay now this is something this is an anticipated exam question so you have a male patient presented with impotency bilateral resting pain the finding in the legs are seen as below what is the level of the pathology that is occurred okay so when you say male impotency bilateral pain as we have already spoken about it this is what we called as the layer syndrome and the layered syndrome is seen at the iottoiac bifurcation it is at the iottoc bifurcation we have already seen across it okay going on to the next one a patient presented with sudden onset of right leg pain investigation was done image was obtained in the shown below what is this image that you can see see it is not a DSA because you will have an imaging prospect it does not look like an MR not a plethoscopy it is an USG Doppler it is going to be your ultrasound Doppler okay next question which of the following is the most likely to be seen during a rupture of sacular anurism okay so when there is an aneurysm that is going to burst it is the aneurysm that is going to rupture in see the options look at the options that you have the options that you have is SD that is subdural hemorrhage SA subericid intracer and hydrostus so where do you have the circular villis it is in the suberoid space so when it ruptures it will cause subericid hemorrhage so answer here is going to be b for bombay the question that they'll ask you is in the context of ber's aneurysm What is the earliest sign of ruptured berries aneurysm the earliest sign of the ruptured berries aneurysm is going to be nucal rigidity okay they'll ask what is the most specific sign or the most characteristic it is your thunderclap headache do not forget about it okay they'll also ask you berries aneurysm is associated with renal disorder in surgical component it is polycystic kidney disease remember in PKD every patient will have or most likely to have a berries aneurysm okay ch now let's go to the next question we have a patient is diagnosed with Stanford B iotic dissection what is the most appropriate initial management of this step so usually when we talk about the iotic dissections we have the DB keys classification following the DB case classification we have the Stanford one okay i'll quickly talk about the iotic dissection classification so that we'll understand better so in the context of iotic dissection based upon the level of dissection and the extent we have the following components so if you take this as a representation of the iota and this is the iotic bifurcation okay now what we have to do is we have to see that from where does the dissection start and where does it end okay so you have something called as DB keys type one so D1 that is DB keys type one that is DB keys type two and DB keys type three so in DB keys type one the dissection starts at the level of the ascending thoracic iota it goes all the way to the iotic bifurcation okay in DBK type two it starts at the ascending iota stays at the level of ascending iota db type three it descends at the descending thoracic iota extend all the way to the iotic bifurcation stanford said that I'm not going to take into consideration of the site and level i'll only take at the site of dissection so these two will become Stanford A this will become Stanford A and this will become Stanford B this will become Stanford B okay now the question that they're asking you so we'll talk about the management also now in the context of the initial presentation see in iotic in iotic dissections you need to be extremely careful about what are you dealing with and which level are you dealing with if they ask you what is the most common site for the iotic dissection I'll write just the important points the most common site for the iotic dissection the most common site for iotic dissection any takers if you're writing your NEPG exam this is like a piece of cake for you what is the most common site for iotic dissection quick feedback thank you Nagesh most common site for iotic dissection it is the right lateral wall of the ascending thoracic iota it is the right lateral wall of ascending thoracic iota it is the right lateral wall of the ascending thoracic iota clear so this is the overall most common site for this right now for Stanford A that is dbake type one and type two it is always referred for surgery that is going to be tacin graft repair for DB case that is type three or stanford B we are going to see whether the patient is going to be stable or unstable so initially you're going to put it on conservative management that is going to be monitor if patient is unstable if patient is unstable then take the patient for surgery that is your dacrine graft repair okay so this is the protocol tha