arteries

Question 1

The semiological analysis of the peripheral pulse

Answer 1

[*] Sites

[*] Rate

[*] Rhythm

[*] Amplitude (pulse volume, intensity)

[*] character

Question 2

PAD
Risk factors

Answer 2

• Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)
• Age 50 to 69 years and history of smoking or diabetes
• Age 70 years and older
• Known atherosclerotic coronary, carotid, or renal artery disease

Question 3

Rate/rythm

Answer 3

Rate- beats/min

• count the number of beats over 15 seconds and then multiply by four
• Slow/irregular – 60 sec.!

Rhythm:

• Regular
• Irregular

[*] Complete arh.
[*] Extrasystolic arh.
[*] Respiratory arh.- NORMAL !!!
–In young
–the heart rate increases slightly during inspiration- vagal tone

Question 4

Pulse intensity

Answer 4

–0, absent
–1, diminished
–2, normal
–3, bounding

Question 5

Pulsus Paradoxus

Answer 5

[*] the blood pressure falls more than 15 mmHg in inspiration (20)
–Tamponade

(It represents an “exagerate” response)

Question 6

Auscultation of the arteries

Answer 6

Question 7

PAD
Cassification

Answer 7

• functional- spasm
• organic- obstruction of the blood flow:
• Acute
• Chronic

Question 8

PAD
causes

Answer 8

• ATS; diabetes
• Buerger disease (Thromboangiitis Obliterans): segmental vascular inflammation, vasoocclusive phenomenon

Question 9

PAD
Clinical Manifestation

Answer 9

Asymptomatic: Without obvious symptomatic complaint (but usually with a functional impairment).

Classic claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest.

“Atypical” leg pain: Lower extremity discomfort that is exertional but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance

Critical limb lschemia: Ischemic rest pain, nonhealing wound, or gangrene

Intermittent claudication- muscle pain (calf muscle)
– ache, cramp, fatigue, during exercise and relieved by rest.
–claudication index

Question 10

PAD Physical exam:

Answer 10

–Absence of the peripheral pulses
–Hair loss, cold legs, pallor (trophic changes)
–Murmur- stenosis
–ulcer, gangrene

Question 11

PAD Differential DG

Answer 11

[*] Peripheral neuropathy
[*] Osteoarthritis of the hip or knee
[*] Venous pathology
[*] Compartment syndrome ( pressure within a limited space compromises the circulation and function of the tissues within that space)
[*] Muscle spasms or cramps
[*] Restless leg syndrome

Question 12

1.Resting Ankle-Brachial Index (ABI)

Answer 12

Step 1: the blood pressure cuff placed on the arm is inflated over the artery until the pulse ceases

Step 2: Turn on the Doppler and place the probe in the area of the pulse; the cuff is slowly deflated

The corresponding sphygmomanometer pressure at the instant the pulse returns provides the systolic blood pressure.

Step 3: the same manner for leg

Question 13

Interpreting the Ankle-Brachial Index

Answer 13

BBorderlineordBorderlineerline

ABI

Interpretation

1. 00–1.29Normal
2. 91–0.99Borderline
3. 41–0.90Mild-to-moderate disease

≤0.40Severe disease

≥1.30Noncompressible

Question 14

Acute ischemia

Answer 14

Embolization: atrial Fi, endocarditis, mitral valve disease, aneurysmal origin, post CV Surgery

Thrombosis: pre-existing ATS plaque

Question 15

Acute ischemia

symptoms

Answer 15

5 P-s”:

• Pulselessness (distal of the level of occlusion)
• Pain
• Palor
• Paresthesia
• Paralysis

–Number 6 of the “P” is recently added: prostration.

Question 16

Buerger disease (trombangiitis obliterans)

Answer 16

• Male, young, heavy smoker
• Small and medium sized arteries and veins
• Lower limbs- usually
• distal limb ischemia: cyanosis, pallor, cold limb, ulcerations or localized gangrene of the digits; secondary Raynaud’s phen.
• Superficial thrombophlebitis

Amputation is common

Question 17

[*] The Stanford classification divides dissections into 2 types: type A and type B.

Answer 17

• Type A involves the ascending aorta (corresponds to the DeBakey types I and II)
• Type B involves the aorta distal to the left subclavian artery (DeBakey type III).

Question 18

The DeBakey- 3 types of dissections:

Answer 18

• Type I involves the ascending aorta, aortic arch, and descending aorta.
• Type II involves the ascending aorta.
• Type III refers to the descending aorta distal to the left subclavian artery

Question 19

Clinical Manifestation of Aortic dissection

Answer 19

• Chest pain: typically with an abrupt and maximal intensity onset, described as ripping or tearing
• Anterior thoracic pain- anterior arch or aortic root dissection
• Neck or jaw pain- aortic arch dissection
• Interscapular pain radiating to lower back or abdomen- descending aorta dissection.
• Blood pressure: decreased due to the cardiac tamponade, hypovolemia or increased due to cathecolamine reaction or the underlying hypertension; significant interarm difference
• Dyspnea- heart failure or tracheal or bronchial compression.
• Acute aortic regurgitation with acute cardiac failure signs
• Acute myocardial infarction
• Cardiac tamponade: muffled heart sounds, hypotension, pulsus paradoxus, jugular venous distension, Kussmaul sign

Question 20

Neurological signs:

Answer 20

[*] syncope, cerebrovascular accident, peripheral nerve ischemia, recurrent laryngeal nerve compression (resulting in hoarseness), irritation of the cervical sympathetic ganglia with Claude-Bernard-Horner syndrome (unilateral ptosis, miosis, and anhidrosis)

Question 21

Gastrointestinal manifestations

Answer 21

involvement of the renal artery, abdominal aorta

Question 22

[*] DVT of the lower limbs

Answer 22

• Distal
• Proximal- the highest risk of PE–Phlegmatia caerulea dolens: due to massive ileofemoral veins obstruction; the leg is usually markedly edematous, painful, and cyanotic
• Plegmatia alba dolens: massive thrombosis and associated arterial spasm; the leg is often pale with diminished or absent distal pulses

Question 23

DVT
Clinica Manifestations

Answer 23

• Edema
• Swelling of the leg
• leg pain
• Tenderness
• Erythema
• Superficial distended veins
• Pulmonary thrombembolism as a primary manifestation- dyspnoea, cyanosis, tachycardia (Mahler sign), fever (Mikaelis sign)
• Homans’s sign (pain- the calf muscles on forced dorsiflexion of the foot)
• Lowenberg sign (the cuff compression test): calf pain at a pressure lower than 180 mmHg
• Lisker’s sign: pain during the percussion of the anteromedial side of the tibia.

Question 24

Upper limb DVT-

Answer 24

[*] cancer, trauma, catheter or sustained effort (the abduction of the arm)

Question 25

DVT Complementary examination

Answer 25

[\*] D-dimer- negative predictive value [\*] Doppler ultrasound [\*] Venography [\*] Magnetic resonance [\*] CT angiogram- for PE

Question 26

CHRONIC VENOUS INSUFFICIENCY Causes

Answer 26

* Congenital absence of the valves * damage of the valves in the superficial and communicating venous systems (secondary to venous thrombosis)

Question 27

CEAP classif.:

Answer 27

[\*] Stage 0: no signs of chronic venous insufficiency [\*] Stage 1: reticular veins/ telengiectasis [\*] Stage 2: varicose veins [\*] Stage 3: edema [\*] Stage 4: skin changes [\*] Stage 5: healed ulcer [\*] Stage 6: active ulcer

Question 28

Chronic Venous insufficienyc symptoms

Answer 28

[\*] Pain [\*] edema [\*] dermatitis- stasis [\*] varicose veins [\*] Ulcer- internal side of the lower limb

Question 29

Linton maneuver

Answer 29

identifies idiopathic varicose veins with normal profound veins: – the elevation of the leg is followed by a promptly emptying of the varicosities (in case of affected deep veins the emptying is prolonged)