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103 Cards in this Set
- Front
- Back
Clenched fist over sternum suggest? |
Angina pectoris |
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what can cough indicate with regard to heart failure? |
symptom of LSHF |
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Dullness replaces resonance when... |
fluid or solid tissue replaces air containing lung or occupies thepleural space beneath percussing fingers. |
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Examples of dullness replacing resonance |
Examples: lobar pneumonia, alveoli are filled with fluid and blood cells;and plural accumulation of serous fluid (pleural effusion), blood (hemothorax),pus (empyema), fibrous tissue, or tumor. |
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Generalized hyperresonance- |
heard over hyperinflated lungs of COPD or asthma. |
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Vesicular breath sounds |
soft and low pitch. Duration: inspiratory sounds last longer thanexpiratory. |
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Bronchovescular breath sounds |
intermediate intensity and pitch. Duration: often in 1st and 2nd interspacesanteriorly and between the scapulae |
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Bronchial |
Loud and high pitched. Duration: Expiratory sounds last longer thaninspiratory. |
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Tracheal |
very loud and high in pitch. Duration: inspiratory and expiratory areequal. |
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Crackles that do not clear after coughing |
may be from abnormalities of the lungs (pneumonia, fibrosis, early heartfailure) or of the airways (bronchitis, bronchiectasis). |
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Wheezes suggest... |
narrowed airways as in asthma, COPD, bronchitis. |
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Asthma |
widespread narrowing of tracheobronchial tree |
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findings suggestive of COPD |
Combinations of symptoms and signs, especially wheezing by self-reportor examination, plus a hx of smoking, age, and decreased breath sounds. |
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percussion with COPD |
Hyperresonant
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Auscultation with COPD |
decreased to absent (associated chronic bronchitis is common) |
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What would you hear with lobar consolidation when performingegophony? |
Consolidation area sounds the ‘ee’ changes to ‘aa’ seen in pneumonia. The “A” is a nasalbleating quality and should be localized. |
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What in particular are you noting when inspecting the anteriorchest? |
Shape of the chest- normal is elliptical. Movement of the chest wall. Local lag or impairment in respiratory movementsLook for deformities or asymmetry, abnormal retraction ofthe lower interspaces during inspiration. |
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Abnormal retraction suggests what conditions? |
-abnormal retractions occur in severe asthma, COPD, or upperairway obstruction. |
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Angina pectoris Process, location, quality, severity, timing, aggrevation, relieve, associated Sx: |
Process:temporary myocardialischemia, usually secondary to coronary atherosclerosis Location: anterior chest,shoulders, arms, jawQuality: pressing, squeezing,tight, heavy, occasionally burning Severity: may be mild to moderateTiming: 1-3 minutes but up to 10. Prolongepisodes up to 20 mins. Aggrevate: exertion rest, nitro nausea |
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Dissecting Aortic Aneurysm: process Location quality severity |
Process: A splitting within the layers of the aortic wall,allowing passage of blood to dissect a channel. Location:Anterior chest, radiating to neck, back, abdomen Quality:Ripping Severity:VERY |
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Dissecting Aortic Aneurysm: Timing aggrevate associated Sx: |
Timing: persistent,abrupt onset, early peak, persistent for hours or more Aggrevate:HTN AssociatedSx: if thoracic, hoarseness, dysphagia, also syncope, hemiplegia, paraplegia |
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Pleuritic pain process location duration severity |
Process: Inflammation of the parietal pleura, as inpleurisy, pneumonia, pulmonary infarction or neoplasm. Location:chest wall overlying process Quality:sharp, knifelike Severity: oftensevere |
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Pleuritic pain timing aggravating factors relieve associated Sx |
Timing: Persistent Aggravating:deep inspiration, coughing, movements of trunk Relieve:nothing listed in text AssociatedSx: of the underlying illness |
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Left sided heart failure process: timing setting |
Process: Elevated pressure in the pulmonary capillary bedwith transudation of fluid into interstitial spaces and alveoli, decreasedcompliance (increased stiffness) of the lungs, increased work ofbreathing. Timing: Dyspneamay progress slowly, or suddenly as in acute pulmonary edema. Setting: Hxof heart disease. |
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LSHF: Aggravating factors relieving factors associated Sx: |
Aggravate: lying down, exertion Relieve:rest, sitting up, though dyspnea may be persistent AssociatedSx: cough, night time dyspnea |
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COPD Process Timing Aggravate: |
Process: Overdistention of air spaces distal to terminalbronchioles, with destruction of alveolar septa, alveolar enlargement andlimitation of expiratory air flow Timing:slowly progressive dyspnea; relatively mild cough later Aggravate:exertion |
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COPD Relieve Associated Sx |
Relieve: rest, dyspnea may become persistent Associatedsx: cough with scand mucoid production |
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Pneumonia process timing Relief associated Sx |
inflammation of lung parenchyma from therespiratory bronchioles to the alveoli Timing:acute illness, timing varies with the causative agent Associated sx: pleuritic pain, cough, sputum, fever, thoughnot necessarily present Setting:varies |
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Spontaneous pneumothorax process timing |
leakage of air into pleural space through blebs on visceralpleura, with resulting partial or complete collapse of the lung. Suddenonset dyspnea, and pleuritic pain |
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Associated Sx spontaneous pneumothorax |
often none. Retrosternal oppressive pain if the occlusionis massive. Pleuritic pain, cough, andhemoptysis may follow an embolism if pulmonary infarction ensues. Symptoms of anxiety. |
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Viral pneumonia or mycoplasma |
Dry hacking cough Acutefebrile, HA, malaise |
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Bacterial pneumonia |
Mucoid or purulent sputum (rustysputum), may be blood streaked, diffusely pinkish, or rusty |
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Asthma |
Cough, with thick mucoid sputum, especially near end ofattack. Mucoid, episodicwheezing and dyspnea Hx.allergies |
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Barrel Chest: |
Increased anteroposterior diameter AP Diameter 1:1 In infancy, aging, and COPD |
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Funnel Chest (Pectus Excavatum) |
Depression of lower sternum Checkclosely for heart murmurs |
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Scoliosis |
Abnormal curvature and rotation |
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Adventitious breath sounds Crackles |
Discontinuous intermittent, non musical and brief like dots in time |
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Fine crackles |
soft, high-pitched, very brief (5-10 msec) |
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coarse crackles |
somewhat louder, lower in pitch, brief (20-30 msec) |
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Wheezes and Rhonchi |
Continuous >250 msec, musical, prolonged (but not necessairly persistent throughout the resp cycle.) like dashes in time high-pitched with hissing or shrill quailty |
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rhonchi
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relatively low pitched with snoring quality suggests secretions in large airways |
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Systole: |
the ventricles contract (closure of mitraland tricuspid valves) (S1) The right ventricle pumps blood into thepulmonary arteries (pulmonic valve is open) Theleft ventricle pumps blood into the aorta |
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Diastole |
• the ventricles relax (closure of aortic andpulmonic) (S2) Blood flows from the right atrium → rightventricle (tricuspid valve is open) Blood flows from the left atrium → leftventricle (mitral valve is open) |
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Cardiac Apex and PMI |
In supine patients with the diameter of the PMI may be as large as aquarter, approximately 1-2.5 cm. |
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PMI > 2.5 cm indicative of... |
LVH, or enlargement, seen in HTN and aortic stenosis. |
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Cardiac pulse |
Provides info about cardiac function and is especially useful fordetecting aortic stenosis or insufficiency of the aortic valve. |
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S1 and S2 heart sounds |
S2>S1 Aortic and Pulmonic S2=S1 Erbs S1>S2 Tricuspid and Mitral |
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What is an invaluable aide in timing the sound of a murmur |
Palpation of the carotid artery during auscultation. The carotid upstroke always occurs insystole immediately after S1 (lub) (closing of tricuspid and mitral) sounds ormurmurs coinciding with the upstroke are systolic; sounds or murmurs occurring aftercompletion of the upstroke are diastolic. |
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Location: |
Assess location with the patient supine, because the left lateraldecubitus position displaces the apical impulse to the left.
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2 points for location: |
Interspaces, usually the 5thor possibly the 4th ICS, MCL. Lateral displacement from cardiac enlargement is seen in heart failure,cardiomyopathy, and ischemic heart disease. |
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Amplitude |
Usually small and feels brisk and tapping. Some young adults have anincreased amplitude or hyperkinetic impulse, when excited or after exercise,duration is normal. |
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Increased amplitude indicates |
hyperthyroidism, severe anemia, pressure overload of theleft ventricle (aortic stenosis), or volume overload of the left ventricle(mitral stenosis). |
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Landmarks of heart valves: Aortic Pulmonic Erbs Tricuspid Mitral |
Aortic 2nd ICS RSB Pulmonic 2nd ICS LSB Erbs 3rd ICS LSB Tricuspid 4th ICS LSB Mitral 5th ICS LSB |
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What position will accentuate a left-sided S3 and S4, mitral murmurs? |
Left lateral decubitus accentuatesS3, S4, mitral murmurs, especially mitral stenosis |
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Sitting leaning forward: |
end exhalation accentuates aorticmurmurs- aortic regurgitation- a soft diastolic murmur. |
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Aortic stenosis location and radiation |
Location: Right 2nd interspace Radiation: to the carotids, down the left sternal border,even to the apex Intensity: sometimes soft but often loud, with a thrill Aids: Best heard pt sitting up and leaning forward |
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Mitral stenosis location and radiation |
Location: usually limited to the apex. Radiation: little or nonePitch: low, use the bell.Aids: turn patient into a left lateral position, heardbetter with exhalation. |
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Careful assessment is essential for detecting what? |
Peripheral arterial disease |
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How many Americans and what percent of those > 80? |
Prevelance increases with age. 7% inadults 60-69 y/o 23% ages 80+ |
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Where is the brachial artery located? |
at the bend of the elbow just medial to thebiceps tendon |
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Radial artery |
on the lateral flexor surface |
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Ulnarartery- |
medial flexor surface, although overlying tissues may obscure the ulnarartery. |
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PAD refers to... |
stenotic, occlusive, and aneurysmal disease of theaorta, its visceral arterial branches, and the arteries of the lowerextremities, exclusive of the coronary arteries. |
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Intermittent claudication |
Pain or cramping in the legs during exertion that is relieved by restwithin 10 minutes. |
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Symptomatic limb ischemia |
with exertion is present in atherosclerotic PAD. |
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Neurogenic claudication |
Pain with walking or prolonged standing, radiating from the spinal areainto the buttocks, thighs, lower legs, or feet |
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What to ask about in regard to PVD |
coldness, numbness, or pallor in the legs or feet or loss of hair overthe anterior tibial surfaces. |
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What does hair loss over the anterior tibiae indicate? |
Occurs withdecreased arterial perfusion. “Dry” orbrown-black ulcers from gangrene may ensue. |
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Ankle brachial index |
Measure systolic blood pressure in the arms and in the pedalpulses, using Doppler ultrasound. |
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Important areas to examine |
Arms- size, symmetry, skin color. Radial pulse, brachialpulse, epitrochlear lymph nodes Abdomen- aortic width, pulsatile mass Legs- size, symmetry, skin color, femoral pulse and inguinallymph nodes, popliteal, dorsalis pedis, and posterior tibial pulses, peripheraledema. |
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What to look for when inspecting the ankles and feet? |
Size,symmetry, and swelling. Venous pattern. Color of skin and nail beds and textureof skin. |
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What might bounding pulses indicate? |
Aortic insufficiency, asymmetric diminished pulses occur inarterial occlusion from atherosclerosis or embolism. |
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How would you grade pulses? |
3+ bounding2+brisk, expected1+ diminished, weaker than expected0 Absent, unable to palpate |
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If you suspect arterial insufficiency, what pulse would you palpate? |
brachial pulse |
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What to assess when inspecting legs... |
Size, symmetry, and any swellingVenous pattern and venous enlargementPigmentation, rashes, scars, ulcersColor and texture of skin, color of nail beds, distributionof hair on lower legs, feet, and toes. |
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Dorsalis pedis pulse |
Feel the dorsum of the foot (not ankle) just lateral to theextensor tendon of the great toe. If youcan’t feel a pulse, explore the dorsum of the foot more laterally. |
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Posterior tibial |
curve fingers behind and slightly below the medial malleolus of theankle. This pulse maybe hard to feel wina fat or edematous ankle. |
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Temperature assessment: |
Coldness, especially when unilateral or associated with other signs,suggests inadequate arterial perfusion. |
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sudden arterial occlusion from embolism or thrombosis causes..... |
pain and numbness or tingling |
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If limb distal to occlusion becomes cold, pale, and pulseless.... |
Emergency treatment required. |
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What is the allen test? |
Useful to ensure the patency of the ulnar artery before puncturing theradial artery for blood samples. Arterialocclusive disease is much less common in the arms than in the legs. |
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Absent or diminished pulses at the wrist are found in.... |
acute embolic occlusion and in Buergers Disease orThromboangiitis obliterans. |
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marked pallor on elevation suggests... |
arterial insufficiency |
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How to assess for pallor on elevation.. |
Raise both legs to about 60 degrees until maximall pallor of the feetdevelops, usually 1 minute. In light-skinned people, either maintenance of normalcolor. Then, ask patient to sit up withlegs dangling down. |
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When comparing both feet, noting the time required for assessing pallor on elevation... look for.... |
Return of pinkness to the skin, normally about 10seconds. Filling theveins of the feet and ankles, normally about 15 sec. |
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Chronic venous insufficiency |
Edema is soft, with pitting on pressure, and occasionally bilateral. Looking for brawny changes and skin thickening, especially near the ankle. |
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Chronic venous insufficiency pigmentation |
ulceration and pigmentation and edema in the feet are common |
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Lymphedema |
Edema is soft int he early stages, then becomes indurated, hard, and nonpitting. Skin is markedly thickened; ulceration is rare. No pigmentation |
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Lymphedema develops when |
lymph channels are obstructed by tumor, fibrosis, or inflammation, and in cases of axillary node dissection and radiation |
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intermittent claudication location of pain |
usually calf muscles, but also may be in the buttock, hip, thigh, or foot, depending on level of obstruction |
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DVT |
tight bursting pain, if present, usually in the calf; may be painless |
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Interpretation of ABI Normal range |
>.90 (with a range of 0.90 - 1.30) |
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Mild PAD |
<0.89 to >.60 |
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Moderate PAD |
<.59 to >.40 |
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Severe PAD |
<.39 |
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Chronic arterial insufficiency pain mechanism pulses color |
intermittent claudication, progressing to pain at rest tissue ischemia decreased or absent pale, esp on elevation; dusky red on dependency |
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Chronic arterial insufficiency edema skin changes ulceration gangrene |
absent or mild edema trophic changes: thin, shiny, atrophic skin; losses of hair over the foot and toes; nail thickened and ridged if present, involve toes or points of trauma on feet |
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Gangrene is present in |
chronic arterial insufficiency |
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Chronic venous insufficiency |
often painful venous HTN color is normal, or cyanotic brown pigmentation may appear thickening of the skin |
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chronic venous insufficiency |
ulceration develops at sides of ankles, especially medially |
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Chronic venous insufficiency borders and ulcers |
borders are irregular, flat, or slightly steep. ulcer contains small, painful granulation tissue and fibrin; necrosis or exposed tendons are RARE. |
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Arterial insufficiency pain |
pain is often severe unless neuropathy masks it. |
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Arterial insuffiency and gangrene |
may be associated; along with decreased pulses, trophic changes, foot pallor on elevation, and dusky rubor on dependency. |