Cardiovascular and Peripheral Vascular Assessment Flashcards
What is contained within the mediastinum
- Heart
- Great Vessels: aorta, pulmonary artery, & superior/inferior vena cava
- Esophagus
- Trachea
- Thoracic duct
- Thoracic lymph nodes
What chamber of the heart is the most anterior ?
Right ventricle
Where can the RV and pulmonary artery be found?
To the left of the sternum @ the level of the sternal angle (base of the heart)
What intercostal space represents the level of the base of the heart
2nd intercostal space
Point of maximal impulse (PMI)
LV behind the RV & to the Left forms the L lateral margin
5th ICS @ left midclavicular line
- 1 to 2.5 cm in supine
- PMI > 2.5 cm = LVH
Where is the PMI in right & left hypertrophy?
RVH - PMI @ xiphoid or epigastric area
LVH- PMI > 2.5 cm
- PMI displaced laterally to MCL
- PMI > 10 cm from midsternal line
What are the atrioventricular valves
Tricuspid & Mitral
What are the semilunar valves
Aortic & Pulmonic
Which valves closing cause S1? vs S2?
S1 = AV closure S2 = SL closure
Where is the aortic valve located?
Right sternal border 2nd ICS
Where is the pulmonic valve located?
Left sternal border 2nd ICS
Where is the tricuspid valve located?
Right sternal border 5th ICS
Where is the mitral valve located?
Left midclavicular 4th ICS
What is an S3 murmur
Mitral valve opens, allowing abrupt blood flow, filling the left ventricle (compliant/ dilated)
- right after S2 (early diastole)
- during LV PASSIVE filling
- can be normal in kids & teens
- heard best at the cardiac apex
- In older adults it represents pathology
What is the pathology of an S3 in an older adult?
the myocardium is usually overly compliant, resulting in a dilated LV
- CHF (systolic)
- Mitral regurg
What is an S4
Increased LV end diastolic stiffness which decreases compliance
- right before S1 (late diastole)
- during LV active filling
- Pathological ventricular stiffness
What is the pathology of an S4?
Non-compliant heart trying to fill but meeting resistance
- HTN
- MI
- Diastolic HF (problem w/ end diastolic filling)
- Worse d/t not feeding coronary arteries
What causes a heart murmur?
Turbulent blood flow
- distinguished by their pitch and longer duration
- indicate valvular heart disease in the older adult
What is the difference between a stenotic valve and a regurgitant valve?
Stenotic = narrowed orifice that obstructs blood flow
Regurgitant = close abnormally and allows backward flow
Murmurs detected during pregnancy should be immediately evaluated especially ________ & ________.
Aortic stenosis & pulmonary hypertension
Where is the SA node located and what is the intrinsic rate?
In the RA at the junction of vena cava inferior & superior)
- Pacemaker rate 60-100
Where is the AV node located and what is the intrinsic rate?
In the distal atrial septum.
- Pacemaker rate 40-60
HR x SV =
Cardiac output
What is a normal EF
60%
What are the 3 components of SV
- Preload
- Afterload
- Contractility
What are causes for decreased RV preload:
- Exhalation (increase intrathoracic pressure in end exhalation in negative press. breathing)
- Dehydration
- Blood pooling
What are causes for increased preload/afterload:
Volume or pressure overload
Pulse pressure =
Systolic - Diastolic
Name 4 factors affecting Blood pressure:
- LV stroke volume
- Distensibility of the aorta & large arteries
- PVR (particularly at arteriolar level, medium size vessel level)
- Volume of blood in the system
Jugular veins can be used to assess what?
Index of right heart pressures & cardiac function
Right Jugular venous pressure (JVP) =
right atrial pressure = CVP & RV-end-diastolic pressure
Jugular venous pulsations
Changing pressures in the right atrium during diastole & systole produce oscillations of filling & emptying in jugular veins
Retrograde blood flow from the atrial contraction just before S1 and systole =
a wave followed by the x descent of continued atrial relaxation
As right atrial pressure begins to rise during right ventricular systole there is a second elevation in the CVP wave form______.
v wave followed by the y descent as blood passively empties from the right atrium into the RV during early & mid-diastole
3 Questions related to the most common manifestations of cardiac disease:
- Is the blood supply to the heart adequate?
- Is the electrical system of the heart functioning normally?
- Is the heart adequately moving blood through the circulation & supplying the organs?
What are the most common or concerning symptoms found in a cardiac health history?
- Chest pain
- Palpitations
- Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
- Edema
- Syncope
What is the most common symptom of coronary heart disease (CHD)?
Chest pain
What is classic exertional pain?
Pressure or discomfort in the chest, shoulder, back, neck, or arm in angina pectoris is seen in 18% of patients with acute MI
What is atypical descriptors of chest pain?
- Cramping
- Grinding
- Pricking
- Tooth or jaw pain (rarely)
Anterior chest pain descriptions
- Tearing or ripping
- Radiating into the back or neck
- Occurs in acute aortic dissection (won’t ever be comfortable, look gray, feeling of impending doom, mottled chest)
Acute coronary syndrome is used to describe what?
The clinical syndromes caused by acute myocardial ischemia = unstable angina, non-ST & ST elevation MI
- Considered life threatening diagnoses such as angina pectoris, MI, dissecting aortic aneurysm, & PE
Women over 65 yo commonly report what type of chest pain?
Atypical.
- Upper back, neck or jaw pain, SOB, paroxysmal nocturnal dyspnea, N/V, & fatigue
What are palpitations?
Unpleasant awareness of the heartbeat.
- Not necessarily a heart disease
- The most serious, VTach, do not produce palpitations
Name 3 ways shortness of breath can present?
- Dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea (PND)
What are clinical considerations if a patient has sudden dyspnea
- Pulmonary embolus
- Spontaneous pneumothorax
- Anxiety
Your patient presents with orthopnea and PND what cardiac pathology do you suspect?
- Left ventricular heart failure
- Mitral stenosis
- Obstructive lung disease
Edema
The accumulation of excessive fluid in the extravascular interstitial space.
- the interstitial tissue can absorb up to 5 L of fluid (10% weight gain) before pitting
What are some causes of edema?
- Cardiac: R or L ventricular dysfunction; pulmonary HTN
- Pulmonary: obstructive lung disease
- Nutritional: hypoalbuminemia
- Positional: dependent edema in feet and lower legs when sitting, or the sacrum when bedridden.
- Renal: periorbital puffiness & tight rings of nephrotic syndrome
- Liver failure enlarged waistline from ascites
Anasarca
Severe generalized edema extending to the sacrum & abdomen
Syncope
A transient loss of consciousness followed by recovery
- Usually caused by vasovagal syncope (most common)
What is the most concerning cause of syncope?
The heart not providing adequate blood flow to the brain, as occurs in end-stage heart failure & arrhythmias
Orthostatic hypotension
- Gravitational redistribution of 300-800 mL of blood
- Due to decreased venous return, inadequate adrenals (norepi) or hypovolemia
Cough syncope (episode of vigorous coughing)
- Reflex vaso-depressor- bradycardia, cerebral hypoperfusion, increased CSF pressure
Micturition syncope
Vasovagal response from emptying bladder
- usually in the elderly when urinating at night
Arrhythmias and syncope are caused from what?
From decreased CO
How does Aortic stenosis or hypertrophic cardiomyopathy cause syncope?
Vascular resistance falls with exercise but CO does not rise due to outflow obstruction - not meeting demand
How does an MI cause syncope?
From decreased CO
What are common disorders that can resemble syncope?
- Hyperventilation: hypocapnia & constriction of cerebral blood vessels & passout
- Hypoglycemia: Unable to maintain cerebral metabolism, epinephrine released
- Fainting from conversion disorder: unknown
General cardiac exam includes:
- BP & HR
- JVP
- Carotid bruit
- Carotid pulse/ upstroke & presence of a thrill
- Anterior chest wall inspection
- Palpate & locate PMI or apical impulse
- Auscultate S1 & S2 in 6 positions from the base to the apex
When listening for murmurs what should you try and distinguish?
- Identify their timing
- Shape
- Grade
- Location
- Radiation
- Pitch
- Quality
When should you use the diaphragm ?
To detect higher frequency sounds
When should you use the bell?
To detect lower frequency sounds: higher grades of stenosis
Where should you place the stethoscope to auscultate a carotid bruits
At the upper edge, level of the thyroid cartilage (on either side)
What usually causes a bruits
CAD or atherosclerosis but can also be:
- tortuous artery
- aortic stenosis
- hypervascularity of hyperthyroid
- external compression from thoracic outlet syndrome
What are the risks of Carotid Stenosis
- 10% risk of ischemic stroke
- Doubles risk of CAD
- 50-69% stenosed = stroke rate is 22% at 5 years
70% stenosed = stroke rate is 24% at 1.5 years
Where do you palpate the carotid?
Palpate the lower 1/3 of the neck
- Avoid pressing on the carotid sinus (@ the top of the thyroid cartilage) = reflex brady & decrease BP
What causes a decreased pulsation in the carotid?
- Low SV
- Local narrowing
- Occlusion from CAD
Carotid pulse characteristics:
Timing = upstroke follows S1 and before S2
- Delayed in aortic stenosis
- Thready in cardiogenic shock
- Bounding in aortic regurgitation
Pulsus Alternans
the rhythm of the pulse remains regular
- the force of the arterial pulse alternates because of alternating strong & weak ventricular contractions
- Almost always indicates severe left ventricular dysfunction
(might hear S4)
Where is pulsus alternans best felt?
By applying light pressure on the radial or femoral arteries
What is Paradoxical pulse?
A greater than normal drop in systolic blood pressure during inspiration
- normally no greater than 3 or 4 mmHg
What symptoms should you look for if your patient has an unstable paradoxical pulse ?
Suspect cardiac tamponade b/c of:
- JVD
- Dyspnea
- Tachycardia
- Muffled heart tones
- Hypotension
Paradoxical pulse is commonly found in what diagnoses?
- Acute asthma
- Obstructive pulmonary disease
- Constrictive pericarditis
- Acute pulmonary embolism
The apical pulse location changes in what conditions?
- Pregnancy = up and to the left
- Ventricular dilation (HF, cardiomyopathy) & mediastinal shift = displaced to anterior axillary line (L of MCL)
- Pericardial effusion = no detection, fluid does not allow sound to be transmitted
Midsystolic murmur
- Between S1 & S2
- Turbulent flow across semilunar valves
- Crescendo is in the middle of systole
Pansystolic murmur
Regurgitant flow across the AV valves
- Heard evenly through systole (no crescendo in the middle)
Late systolic murmur
Usually Mitral valve prolapse proceeded by a click OR
- MV regurgitation
Early diastolic murmur
Regurgitant flow over incompetent SL valves
Mid-diastolic murmur
Turbulent flow across AV valves
Late diastolic murmur
Turbulent flow across AV valves
What are causes of continuous murmurs?
- Congenital patent ductus arteriosus
- AV fistulas
- Venous hums
- Pericardial friction rubs
Grading of systolic murmurs
The CRNA does not grade but should know the scale 1-6:
1 - Softer than S1&S2, very faint
2 - Equal to S1&S2, hear immediately
3 - Louder than S1&S2
4 - Louder than S1&S2 w/ palpable thrill
5 - Louder than S1&S2 w/ thrill, may be hear w/ stethoscope partially off chest
6 - Louder than S1&S2, w/ thrill, may be heard w/ stethoscope entirely off the chest
Grading of Diastolic murmurs
1-4:
1 - Barely audible
2 - Faint but immediately audible
3 - Easily heard
4 - Very loud
Your patient’s JVP is 5 cm above the sternal angle, carotid upstroke is brisk w/ a bruit over the L carotid artery. PMI is diffuse, 3 cm in diameter, palpated at the anterior axillary line in the 5th & 6th ICS. S1 & S2 are soft w/ S3 present at the apex. High pitched harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla. What does this suggest?
- PMI = increased in size & displaced
- JVP normal = 4 cm above sternal angle
- HF
- Volume overload (JVP/edema)
- Left carotid occlusion
- MV disease
Holostolic murmur = begin with S1 & continue throughout systole. - often regurgitant; a common cause is mitral regurgitation
If your patient presents with MV regurgitation do you want a fast or slow heart rate ?
Normal to fast = keep a forward flow
- if you slow the heart rate down w/ regurg you give the blood more time to backflow
AHA concepts of ideal cardiovascular health?
- BMI < 25 kg/m2
- Non-smoker
- Physically active
- Follows a healthy diet
- Untreated cholesterol < 200 mg/dL
- BP < 120/<80 mmHg
- Fasting BG < 100 mg/dL
(only 4% of Americans meet all 6 criteria)
What is the leading cause of death in women?
Cardiovascular disease
- about 2/3 of all US women are overweight or obese
- contributes to epidemic of type 2 DM, & increasing risks for MI and stroke (60%)
What are some unique factors that predispose women to having a stroke ?
- Pregnancy
- Hormone therapy
- Early menopause
- Preeclampsia
Risk factors for Cardiovascular health (8):
- Family hx of premature CVD
- Smoking
- Unhealthy diet
- Physical inactivity
- Obesity
- HTN
- Diabetes
- Increased lipids
Risk factors for primary (essential) HTN (7):
- Age
- Genetics
- Black race
- Obesity & wt. gain
- Excessive salt intake
- Physical inactivity
- Excessive alcohol use
Causes for secondary HTN (10):
- OSA
- CKD
- Renal artery stenosis
- Medications
- Thyroid disease
- Parathyroid disease
- Cushing syndrome
- Hyperaldosteronism
- Pheochromocytoma
- Coarctation of the aorta
What is the American College of Cardiology (ACC) and AHA recommendations for BP
- Existing CVD = 130/80 mmHg
- Patients who have had a stroke or TIA = 140/90 mmHg
What are the 3 layers of issue in an artery
- Intima
- Media
- Adventitia
What is Atherosclerosis?
Chronic inflammatory disease initiated by injury (i.e., smoking or HTN) to vascular endothelial cells
Where does atherosclerotic plaque begin to form?
In the Intima
- circulating cholesterol particles, especially LDLs, are exposed to proteoglycans from the extracellular matrix, undergo, oxidative modification, & trigger a local inflammatory response
Where do you assess the arterial pulses?
Arms & Hands:
- Brachial, radial, & ulnar
Abdomen:
- Superior mesenteric, celiac, inferior mesenteric arteries
Legs:
- Femoral, popliteal, posterior tibial, dorsalis pedis arteries
How does the venous intima prevent clots from forming?
Consists of nonthrombogenic endothelium
Where does the abdominal visceral veins drain?
Drain into the portal vein
- Supplies ~75% of the blood flow to the liver
Which veins are more susceptible to irregular dilation?
Due to weaker wall structures, the leg veins are susceptible to irregular dilation, compression, ulceration, & evasion by tumors
Most filtered fluid returns to circulation as _______.
Lymph
Any alteration in what 3 things can cause edema
- Venous capillary pressure
- Capillary osmotic pressure
- Abnormal fluid balance (exogenous administration or by resorption by the kidney)
What characterizes pitting edema?
Edema that is compressible, or lessens when external pressure is applied
What characterizes lymphedema?
Obstructed lymphatic drainage, usually not compressible
- initially soft and pitting then changes to hard non-pitting
skin thickened
ULCERs are RARE
> 3 cm swelling
Lymphadenopathy
Enlarged lymph nodes, with or without tenderness
What is the difference between local or generalized lymphadenopathy
Local = a causative lesion in the drainage area (unilateral)
Generalized = enlarged nodes in at least two other non-contiguous lymph node regions
What is it called when your patient presents with cramping in the legs on exertion but relief with rest?
Intermittent claudication
Peripheral arterial disease
Atherosclerotic disease distal to the aortic bifurcation
- marker for CV morbidity & mortality
= functional decline
What are the presenting symptoms of PAD
Almost always involve:
- pain
- swelling
- discoloration in the area of arterial distribution
(same risk factors as CAD)
What is it called when your patient presents with pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet?
Neurogenic claudication
Most PAD has minimal symptoms. 2 types of atypical leg pain occur prior to critical limb ischemia, what are they?
Leg pain on exertion & rest
- this pain can begin at rest & carry on (exertional pain that does not stop when the patient stops walking)
PAD warning signs (6):
- Fatigue, aching, numbness, or pain that limits walking or exertion
- Erectile dysfunction
- Poor healing/non-healing wounds of the feet or legs
- Pain present at rest in the lower leg/foot & changes when standing or supine
- Abdominal pain after meals (food fear/ wt. loss)
- 1st degree relative w/ ABD aortic aneurysm
Your patient with a hx of PAD states they are having pain in the buttock/hip, what artery is affected ?
Aortoiliac artery
Your patient with a hx of PAD states they are having pain in the Genitalia, what artery is affected ? What other symptom might they have?
Aortoiliac-pudendal artery
- Erectile dysfunction
Your patient with a hx of PAD states they are having pain in the thigh, what artery is affected ?
Common femoral or aortoiliac artery
Your patient with a hx of PAD states they are having pain in the upper calf, what artery is affected ?
Superficial femoral artery
Your patient with a hx of PAD states they are having pain in the lower calf, what artery is affected ?
Popliteal artery
Your patient with a hx of PAD states they are having pain in the foot, what artery is affected ?
Tibial or peroneal artery
Your patient presents w/ PAD and Abdominal, flank, back pain. What is your primary concern?
Abdominal aortic aneurysm (AAA)
Abdominal aortic aneurysm (AAA) may cause symptoms by compressing on what 3 things:
- Bowel
- Aortic branch arteries
- Ureters
Acute onset of abdominal, flank or back pain suggest what diagnoses?
Mesenteric ischemia from:
- arterial embolism
- arterial or venous thrombosis
- bowel volvulus or strangulation
- hypoperfusion
Failure to detect acute symptoms can result in necrosis or death
If abdominal, flank, or back pain is relieved by sitting or bending forward what might this suggest?
Spinal stenosis
- may also present as bilateral buttock or leg pain
Food fear and weight loss with a patient w/ a hx of PAD suggest?
Abdominal pain after meals related to oxygen supply-demand mismatch
= CHRONIC intestinal ischemia of the Celiac or superior/ inferior mesenteric arteries
DVTs usually present as
unilateral or asymmetric swelling of the extremities
- individual clinical features have poor diagnostic value
If you suspect a DVT in a patient with a CVC what questions should you ask?
- Arm discomfort
- Pain
- Paresthesia
- Weakness
If you suspect a DVT in a patient you understand the individual clinical features are a poor diagnostic value and you should use what?
A well validated formal clinical scoring system like the:
Wells Clinical Score
&
the Geneva Score
PAD physical exam of the arms should include?
- Inspect the upper extremities:
- size, symmetry, swelling, venous pattern, color
- Palpate the upper extremities:
- radial pulse, brachial pulse, epitrochlear lymph nodes (elbow)
PAD physical exam of the abdomen should include?
- Auscultate the abdomen: aortic, renal & femoral bruits
- Inspect & palpate the aortic width & pulsatation
- Palpate the inguinal lymph nodes size, consistency, discreteness, & any tenderness
PAD physical exam of the legs should include?
- Inspect the lower extremities: size, symmetry, swelling, venous pattern, skin color, temperature (cooler d/t weak walls), ulcers, hair loss
- Palpate the femoral, popliteal, dorsalis pedis, posterior tibial pulses, temperature, swelling, & edema
Physical exam of the vasculature should include ?
- Measure the BP in both arms
- Palpate the carotid upstroke
- Auscultate for bruits
- Palpate the aorta & assess its maximal diameter
- Ankle brachial index to check for insufficiency
What is the Grading of pulses ?
0 = absent, unable to palpate 1+ = Diminished, weaker than expected 2+ = Brisk, expected (normal) 3+ = Bounding
Your patient presents with bounding carotid, radial & femoral pulses what is your differential diagnosis?
Aortic regurgitation
Your patient presents with pulsus parvus (weak pulses) what is your differential diagnosis?
Atherosclerotic PVD
Your patient presents with pulsus tardus (sluggish pulses) what is your differential diagnosis?
Aortic stenosis or low cardiac output
How does Raynaud disease clinically present?
Wrist pulses are typically normal, but spasm of the more distal arteries causes episodes of sharply demarcated pallor of the fingers
- can present in the feet as well (distal to the ankle)
If you suspect a DVT in the lower leg what will you see clinically?
Calf asymmetry > 3 cm (increases the likelihood ratio >2.20)
- Have to r/o muscle tear/trauma, baker cyst, and muscular atrophy
Superficial thrombophlebitis =
Local swelling, redness, warmth, & a subcutaneous cord
Cellulitis
Asymmetric warmth & redness over the calf
Venous thromboembolism
Chronic venous insufficiency from prior DVT, incompetent venous valves; or lymphedema
= Unilateral calf & ankle swelling & edema
If you patient has bilateral lower leg edema, what should you suspect?
- HF
- Cirrhosis
- Nephrotic syndrome
Patient presents with ulcers or sores on the feet, what is your differential diagnosis?
Peripheral vascular disease
Varicose veins
Dilated & tortuous veins, may feel somewhat thickened walls
Chronic venous insufficiency
Brownish discoloration or ulcers just above the malleolus
- may be bilateral w/ soft and pitting
Lymphedema & advanced venous insufficiency will present with?
thickened, brawny skin (non-acute)
Where should you measure the calves if you notice unilateral swelling or edema in the legs?
10 cm below the tibial tuberosity
If you suspect an occlusion in the lower extremity what clinical signs will you see?
- All pulses distal will be affected
- Postural color change from supine to standing
If your patient has an aneurysm how will this affect the pulses?
Exaggerated & widened pulses
What are the clinical signs of an acute arterial occlusion from embolism or thrombosis?
Pain, numbness, or tingling.
The limb distal to the occlusion becomes cold, pale, and pulseless = EMERGENCY
Poikilothermia
Relative hypothermia of one extremity as compared with another
1+ scoring of pitting edema
Barely detectable impression when finger is pressed into skin
2+ scoring of pitting edema
Slight indentation; 15 seconds to rebound
3+ scoring of pitting edema
Deeper indentation; 30 seconds to rebound
4+ scoring of pitting edema
> 30 seconds to rebound
A painful, pale, swollen leg, w/ tenderness in the groin over the femoral vein suggests?
Deep iliofemoral thrombosis
How should you palpate the veins in the calf?
With the patient’s leg flexed at the knee & relaxed:
- gently compress the calf muscles against the tibia and search for any tenderness or cords
Homan sign
Discomfort behind the knee with forced dorsiflexion on the foot
- Not a reliable test for DVT
How to perform an ankle-brachial index?
- Patient supine for 10 min
- Measure SBP of brachial pulse w/ doppler (avg. 2 readings)
- Measure SBP of dorsalis pedis pulse w/ doppler (BP around calf)(avg. 2 readings)
How do you calculate an ABI
The ratio of blood pressure measurements in the foot and arm
- should be recorded to two decimal places
Right ABI = highest pressure in Right foot/ highest pressure in BOTH arms
Left ABI = highest pressure in Left foot/ highest pressure in BOTH arms
What is a normal ABI?
Normal range = 0.90 to 1.40
- pressure is normally higher in the ankle than the arm
>1.40 = noncompressible calcified vessel
< 0.90 = diagnostic of PAD
< 0.5 = severe PAD
What are the AHA/ACC practice guidelines for ABI screening for PAD?
Screen when only risk factors present
- sensitivity of an abnormal ABI is low
- specificity is 99%
- the test has high positive & negative predictive values (both > 80%)
What are the USPSTF recommendations for AAA screenings?
Grade B recommendation for 1-time ABD US screening of men ages 65-75 yr who have smoked more than 100 cigarettes in a lifetime
- Women are inconclusive
Thromboangiitis Obliterans (Buerger Disease)
Inflammatory process
- non-atherosclerotic occlusive ds. of sm-med. arteries & veins (not plaque related)
- usually digits or toes on two limbs
Progress from sm. ulcerations to gangrene
- Migratory phlebitis
Compartment Syndrome
Increased pressure in a fascial compartment
- collapses arterial supply causing nerve damage = tingling, burning, numbness
- Dusky red skin, shiny
- Does not have to be trauma related can result from an athlete w/ a muscle tear
- EMERGENCY!
Acute Lymphangitis
Acute infection
- usually strep or staph from portal of entry
- Red streak on skin with tenderness (follows a demarcated line)
- Enlarged lymph nodes
- Seen in IV drug abuse
- FEVER
Acute Cellulitis
Bacterial infection of skin
- usually strep or staph
- red, edema, warm
- lesion can be demarcated from skin
- enlarged lymph nodes
- FEVER
Erythema Nodosum
Painful raised bilateral lesions from the inflammation of subQ fat
- autoimmune
- pretibial lower legs, extensor arms, buttocks, & thighs
- red initially then fade to violet/red-brown
- NO ulcerations
- FEVER, malaise
