Case Wrap Ups (Clin Med Lab Midterm) Flashcards
Clues to help you Dx PAD w/ cludication
- Pt able to walk a discrete distance before pain
- Sitting and resting relieves pain
- Pain returns with walking again
- Pain in legs when elevated (such as in a recliner)
- Dangling legs down relieves pain
- Diminished pulses, smooth hairless legs that are cool to the touch, thickened toenails, color changes in the legs, +Buerger test
- ABI test <0.9
What is the Buerger test?
- Have Pt lay supine
- Elevate both legs to a 45 degree angle, hold legs there for 1-2 minutes
- If pallor in the feet/lower extremeties occurs while legs are elevated this is a (+) buerger test and indicates ischemia
- Pt should then sit up and hang legs over side of bed, color should return to the legs (usually blue and then red)
What is peripheral Artery Disease?
- Arterial disease that affects the peripheral vasulature, most commonly from atherosclerosis
- Lipid and fibrous material accumulate between the intimal and medial layers of the vessel leading to narrowing for the vessel
- Ischemia results from poor blood perfusion
- Not enough blood is able to perfuse the limbs to meet their needs.
Signs and Symptoms of PAD
- Can be asymptomatic
- Intermittent claudication
- Atypical pain
- Pain at rest
- Non healing wounds usually on feet
- Ulcers
- Gangrene
- Dry or wet
- Thin, hairless/shiny skin
- Cool skin
- Blue toe syndrome
- Embolic occlusion of an artery to the toe caises ischemia of the toe, turing it blue.
What does this describe?
- Exertional leg pain that occurs after walking a certain distance
- Pain resolves with rest
- Pain retunrs after starting to walk again and walking the same distance as before
- Pain is often in the buttocks, hip, thigh, or leg
Claudication
Claudication in the hips and buttocks with diminished pulses in the groin (one side or both) indicates disease in which vessel?
Aortoiliac disease
What is Leriche syndrome, and what vessel blockage is it associated with?
- Triad of cludication, absent or diminished femoral pulses and ED
- Aortoiliac disease
Claudication in the thigh is associated with which vessel?
Common femoral artery
Claudication in the upper 2/3 of the calf is associated with which vessel?
Superficial femoral artery
Claudication in the lower 1/3 of the calf is associated with which vessel?
Popliteal artery
Claudication of the foot is associated with which vessels?
Tibial and peroneal arteries
Claudication occurs most commonly where?
In the calf
What are the symptoms of acute limb ischemia and it’s Tx?
Is a limb threatening emergency
- Sudden severe pain
- Cold, pale, pulseless limb
- Immobile
- No sensation
- Or parethesias
- Start heprin immediatly and get to vascualr surgery for immediate revascularization
What type of ulcer does this describe?
- Location
- Over toe joints, malleoli, anterior shin, base of heel, pressure points
- Apperance
- Irregular margins, dry and often pale or necrotic
- Callus rarely present
- Foot temp
- Warm or cold (usually cold)
- Severe pain
- Abscent arterial pulses
- Variable sensation in limb
- Skin is shiny, hairless
- Rubor of foot when dangling
- Pallor of leg and foot when elevated
- Reflexes are present
Arterial ulcer
What type of ulcer does this describe?
- Location
- Medial and lateral malleolar area above boney prominence
- Posterior calf may be enlarged
- Apperance:
- Irregular margins
- Pink or red base that may be covered with fibrinous yellow tissue
- Exudate is common
- May be large and circumferential
- No callus present
- Foot is warm
- Mild-severe pain (usually mild)
- Arterial pulses are present
- Sensation in limb is present
- Skin changes
- Erythemia
- Brown-blue hyperpigmentation
- Edema
- Dry skin
- Varicose veins commonly seen
- Reflexes are present
Venous ulcer
What type of ulcer does this describe?
- Location
- Plantar surface of foot over metatarsal heads, heel, pressure points
- Apperance
- Punched out ulcer
- Can be superficial or deep
- Red base
- Ulcer has a calloused border
- Foot is warm to touch
- Not painful
- Arterial pulses may be present or absent
- Tactile, pain, temp, and vibratory sensations are absent
- Skin changes
- Waxy or shiny
- Hair loss
- may be taut
- Dry
- non-pitting edema may be present, especially on dorsal foot
- Reflexes absent
Neuropathic ulcer
What is an Ankle brachial index and what is it used for?
- Ratio of ankle systolic BP divided by the brachial systolic BP
- Is done using a Doppler probe
- Used to diagnose PAD
- Normal range is 0.91-1.3
An ABI less than or equal to 0.90 is diagnostic of what?
PAD (an ABI of 0.90 or less also indicates areterial stenosis of 50% or more)
An ABI greater than 1.3 indicates what?
Calcified vessels
When is exercise testing done for PAD?
- May be used in patients with atypical pain and/or cludication who have a normal ABI
- Gives the most objective evidence for how fucntionally limited someone is
- Can be used to mesaure response to PAD and cludication treatment
- If after Exercise a Pts ABI decreases by 20% or more, that is diagnostic of arterial obstruction
When would vascular imaging be done on someone who has PAD?
- When there is already a plan for intervention
- Provides visualization of the level and extent of the disease
- CT angiography is the initial study
-
Conventional arteriography remains the gold standard for vascular imaging
- Especially in cases of acute ichemia as simultaneous intervention is possible
Main treatments for PAD
- Risk factor modification
- Smoking cessation, DM control, HTN control, weight loss
- Long-term antithrombotic therapy
- ASA or Clopidogrel (Plavix)
- Lipid-lowering therapy with at least a moderate intensity statin
- Irrespective of LDL cholesterol level
Treatment options for claudication
- Supervised exercise program initially
- Cilostazol (Pletal) may help reduce claudication pain
- Revascularization surgery
- For life/limb threatening ischemia
- Or
- Pts with significant/disabling symptoms that are unresponsive to lifesyle modifications and medications
- Stenting or bypass is surgery of choice
How does Cilostazol work?
It is a phosphodiesterase-3 inhibitor which leads to an increase in CAMP. Increased CAMP leads to inhibition of platelet aggregation. Cilostazol also causes vasodilation and inhibits vascular smooth muscle proliferation.
Which Pts is Cilostazol absolutley contraindicated for?
- Any Pt with CHF
- Decreases survival
- Pts with CAD
- Increases risk of angina and MI
S/E of Cilostazol (Pietal)
- Headache
- Diarrhea
- Infection
- Rhinitis
What is PAD a strong perdictor of?
Adverse cardiovascualr outcomes (is regarded as a CHD risk equivalent)
Diabetes, increased pack year smoking hx, lower ABI are predictors for what in someone with PAD?
Progression to critical limb ischemia
What is the risk of major limb amputation for Pts with intermittent cludication?
- 7% over 5 years
- 12% over 10 years
Define:
- Acute rhinosinusitis
Symptoms < 4 weeks
