Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
38 Cards in this Set
- Front
- Back
|
What is the cause of a weakened/delayed pulse in one extremity compared to the other?
|
Elderly - atherosclerosis or aortic dissection
Younger - coarction |
|
|
RAYNAUD'S PHENOMENON
- process and explanation? |
= Exquisite sensitivity of hands/fingers to cold
- Spasm of digital arteries --> finger ischemia - "Triple Response": 1. Pallor (due to ischemia) 2. Cyanosis (due to increased O2 extraction from trapped, non-circulating RBCs) 3. Rubor (due to reperfusion after release of arterial spasm) - this phase often asoc'd with finger numbness/pain |
|
|
RAYNAUD'S PHENOMENON
- clinical significance? |
Often precedes several imporant disorders:
- connective tissue diseases - various blood disorders - arterial compression - vasculities/atherosclerosis - drugs/toxins - miscellanious ****20% patients with Raynaud's seem to have no underlying disorder --> thus, they have "Raynaud's Disease" |
|
|
What is the purpose of the Allen Test?
|
Bedside maneuver to assess patency of RADIAL ARTERY, ULNAR ARTERY, DEEP PALMAR ARCH
|
|
|
What are the 2 ways to conduct an Allen Test?
|
1. compress radial artery and have patient clench/unclench hand until blanched --> allow relaxation of hand, and ulner side should refill capillary bed within 5 seconds
- If absence/delay of refilling - (+) test - occlusion of either ulnar artery or deep palmar arch * Repeat on other arm and compare * Repeat whole thing compressing ulnar artery 2. Compress both radial and ulnar arteries and have patient clench/unclench hand until blanched --> when patient relazes hand, release pressure on only ulnar artery --> measure time for refilling - If absence/delay of refilling, do brachial stick or arterial puncture on other hand * Repeat by releasing pressure on radial artery |
|
|
What is Peripheral Vascular Disease?
Causes? Risks associated? |
= obstructive condition of lower extremity arteries
- Usually caused by atherosclerosis - At risk for diabetes, hypertension, CAD, cerebrovascular disease, aneurysms **4-6-fold increase in CV mortality!! |
|
|
What are pedal pulses? How common are their absences?
|
Dorsalis Pedis - undetectable in 10% healthy ppl
Tibialis Posterior - undetectable in 10% healthy ppl *Note: usually congenital loss in one artery leads to compensatory increase in the other Less than 2% healthy ppl lack both pedal pulses! |
|
|
Symptoms of PVD?
|
**Claudication - intermittent limb pain, usually triggered by activity
- exertional weakness of muscles - parasthesia when resting the limb - poor healing of sores, ulcerations *** Both pedal pulses will be absent in PVD! |
|
|
What parts of the legs and what pulses will be affected when PVD occurs:
- distal aorta (above knee) - femoropopliteal (above knee) - peroneotibial (below knee) |
Distal Aorta
- claudification of buttocks, thigh, calf - all lower extremity pulses lost Femoropopliteal - claudification of calf - femoral pulse present, all pulses below lost Peroneotibial - claudification might affect foot (or be absent) - Only loss of pedal pulses *Least common form of PVD |
|
|
What are the main 4 physical findings of PVD?
|
1. Decreased/absent pulses
2. Atrophic changes in foot (hair loss, discoloration of skin, cold, nail growth problems, etc.) 3. Vascular Bruits - over involved artery (iliac, fem, pop) 4. Increased venous filling time |
|
|
How do you test for increased venous filling time?
How long is abnormal?? |
-Lying supine, identify prominent vein in pt's foot
-Lift leg up 45 degrees for 1 minute -Patient should sit up and lower foot over edge of table -Measure time for vein to become turgid and visible ** >20 seconds = abnormal!! |
|
|
If patient has bilateral pedal pulses, do they have PVD?
|
Probably not...
BUT as many as 1/3 pts with PVD may have palpable pedal pulses |
|
|
What signs can indicate the distribution of PVD?
|
abnormal:
- femoral pulse - iliac bruits - limb bruits - Buerger's test - warm knees |
|
|
What is the Buerger Test?
|
Bedside test to assess arterial perfusion to leg - examines color of leg, first when elevated, then when lowered
Stage I - supine; raise both patient's legs to 90 degrees for 2 min --> pallor - poorer arterial supply, lower angle allows pallor Stage II - patient sits up; lower legs over edge of table for 2 min --> color returns --> skin turns first blue (blood deoxygenated as passes thru ischemic tissue), then red flush from toes upward(reactive hyperemia) *Positive test when excessive pallor with elevation and intense rubor with dependency |
|
|
What is the name of the sound of turbulent flow (a) over the heart, (b) within an artery, (c) within a vein
|
heart - murmur
artery - bruit vein - hum |
|
|
What are the predisposing factors for diabetic foot?
|
#1- peripheral neuropathy (loss of protective sensation and muscular coordination)
2. atherosclerotic arterial disease (diabetics esp prone to infrapopliteal arterial atherosclorsis) |
|
|
How common is peripheral neuropathy in diabetics?
|
25% diabetics for >10 years
50% diabetics for >20 years |
|
|
Describe diabetic peripheral neuropathy
- distribution and sensations - racial epidemiology - how to reduce rates of lower extremity amputation |
* Stocking-and-glove distribution
- First parasthesias, then complete loss of sensation - Most in Latinos and Native Americans - Prompt and meticulous foot care - reduce rates of amputation by 50-80% |
|
|
How to diagnose peripheral neuropathy in diabetics?
What is a positive diagnosis? |
Nerve conduction studies used to be the gold standard...
SEMMES-WEINSTEIN (SW) MONOFILAMENT TEST - nylon filament is lightly pressed against skin in different locations --> buckles under certain consistent amounts of pressure *Use 5.07 filament (10g pressure) Positive Test: ***When patient can't feel filament in 4 out of 10 sites OR ***When can't feel at 3rd and 5th metatarsals heads (2-site SW test) |
|
|
Describe an ulcer due to chronic venous stasis
|
- usually located at perimalleolar area of inner ankle
- skin changes - brown hyperpig, dermatitis, skin thickening/induration - painless - warm - no gangrene |
|
|
What should the physical exam evaluate in a pt with diabetic foot ulver?
|
- examine the ulcer
- assess the possibility of vascular insufficiency - assess the possibility of peripheral neuropathy |
|
|
Diabetic Foot Ulcer
- what are the most common locations? - what other physical findings are often associated? |
Location
- areas subjected to weight-bearing (bottom of metatarsal heads, tips of prominent toes, tips of hammer toes) - areas subjected to trauma(heels, malleoli) - areas subjected to stress (dorsal portion of hammer toes) Physical Findings - hypertrophic calluses - brittle nails - hammer toes - fissures |
|
|
What is Charcot's Foot?
What conditions can lead to Charcot's Foot? |
= neuropathic osteoarthropathy
- caused by both sensory loss and motor loss - Foot is convex with rocker-bottom appearance - Small fractures remain unnoticed until bone/joint deformities become severe - Ulcerations form over pressure points - sinus tracts may lead to osteomyelitis **Diabetics uniquely predisposed - Tertiary Syphilis - Charcot-Marie-Tooth Disease |
|
|
What fluids can cause edema?
|
-Serum (venous edema)
-Lymph (lymphadema) -Fat (lipadema) |
|
|
What is pitting? How do you elicit pitting edema? How do you grade pitting edema?
|
= well defined depression in soft tissue, following application of pressure
*Less viscious and protein-rich the fluid, more likely there will be pitting -Press thumb over tibia/dorsum of feet/retromalleolar areas for 1-2 seconds *Pitting graded from 1-4 (4 is worst) |
|
|
Specifically, which types of edema elicit pitting and which do not?
|
Pitting: venous edema, low-protein edema
Early pitting, then none due to inflamm and fibrosis: lymphadema, inflammatory edema No pitting: lipidema |
|
|
Which types of edema have high protein content in fluid?
|
Lymphadema and inflammatory edema (thus pitting occurs early on, but then gets less and less)
|
|
|
What types of edema are associated with pain?
|
ONLY inflammatory edema
|
|
|
What is the cause of venous edema?
|
- biventricular or R ventricular failure (can be assessed with neck vein distention)
- venous insufficiency |
|
|
What is the difference between Primary and Secondary Lymphadema?
|
PRIMARY EDEMA
- congenital abnormality of lymph system - bilateral - onset before 40 y.o. - more common in women SECONDARY LYMPHADEMA - due to damage to lymphatics from infection, radiation, surgery, cancer - unilateral - same prevalence in M and F |
|
|
How can you differentiate edema caused by DVT v. CHF?
|
DVT causes unilateral edema
|
|
|
Trandelenburg's Test
- purpose? - process? |
To assess functioning of valves of leg veins
- supine patient --> raise legs above level of heart until veins completely drained and collapsed - tourniquet mid-thigh to cut off greater saphenous vein - patient stands up - release tourniquet after 1 minute - observe leg veins * Refill of saph should be SLOW (less than one min) * If refills rapidly BEFORE tourn removed, backfilling from incompetent valves of communicating veins * If refills rapidly AFTER tourn removed, backfilling from incompeteny valves of saph vein itself **arterial insufficiency can cause false neg |
|
|
What is a special function of the saphenous vein IF it has incompetent valves?
|
Can be used as a manometer to measure intraabdominal pressure (like internal jugular for right atrium)
|
|
|
Other than the Trendelenburg Test, what can be used to examine leg vein valves?
|
- Press on a variose vein below knee to engorge it
- Simultaneously, flicker teh same vein above the knee - If the impulse is transmitted down the leg to below the knee (backwards down vein), there is valvular insufficiency |
|
|
What are common symptoms of DVT?
|
leg pain and swelling
|
|
|
How accurate is a physical exam for DVT?
What are the main/important physical findings that suggest a DVT? |
Physical exam is NOT very accurate!!
The only physical findings are: -tenderness -swelling -calf asymmetry (if new onset) |
|
|
What 5 clinical finding as associated with a DVT?
|
1. swelling below knee
2. swelling above knee 3. recent immobility 4. cancer 5. fever |
|
|
What are major risk factors for DVT?
How well are they correlated? |
- immobility/paralysis
- recent surgery/trauma - malignancy - cancer - chemotherapy - >60 y.o. - family history of venous embolism - pregnancy - estrogen use **Major risk factor present in ~1/2 patients with DVT |
