Clin Med Lab Final New stuff Flashcards
signs from Hx indicative of PAD
`1.Pt can walk discrete distance prior to pain
- Sitting helps
- Pain resumes with activity again
- Pain in legs with reclining in chair
- Advil does not help
- PMH (smoking, obese, HLD, etc.)
Physical Exam findings in PAD (5)
- Diminished pulses
- Smooth hairless legs that are cooler to touch
- Thickened toenails
- Color changes
- Buerger test
Buerger Test (2 parts)
- Elevate legs 45 degrees for 2 min.
Pallor indicates poor perfusion/ischemia - Next, patient sits up and hangs their legs over the edge of the bed
Color should return to the legs
Skin generally becomes blue then red
Arterial disease that affects the peripheral vasculature, most commonly from atherosclerosis
PAD
Clinical SSx of PAD (10)
Asymptomatic Intermittent claudication Atypical pain Pain at rest Nonhealing wounds Ulcers Gangrene Thin, hairless/shiny skin Cool skin Blue toe syndrome
Exertional leg pain that classically occurs after a certain distance of walking
Resolves with rest
Claudication
Buttock & Hip Claudication is indicative of
Aortoiliac Dz
Aching, may have weakness of thigh or hip with walking. Diminished pulses in 1 or both groins
Aortoiliac Dz
claudication + absent or diminished femoral pulses + ED
Leriche syndrome
Thigh Claudication
Common femoral artery
Claudication of Calf: Upper 2/3
Superficial Femoral Artery
Claudication of Calf: Lower 1/3
Popliteal artery
Foot Claudication vessel involved
Tibial & Peroneal artery
6 P’s of Acute Limb Ischemia
Pulseless Paralysis Perishingly cold Paresthesias Pallor Pain
Tx of Acute Limb Ischemia (2)
Start heparin & revascularization
STAT
How to measure ABI?
NL?
Dx of PAD?
Dx of calcified vessels?
Ratio of the ankle systolic blood pressure
divided by
the brachial systolic pressure
0.91-1.3
PAD <0.9
calcified vessels >1.3
What do you measure PAD arterial extent with?
Doppler probe
an _____ ___________ _________ gives the most objective evidence of how much someone is functionally limited by PAD
Exercise treadmill test
Might be considered in patients with atypical pain & a normal ABI
Performed in a vascular lab
Exercise treadmill test
An ABI that ↓ ____% after exercise is diagnostic of arterial obstruction
20
Vascular imaging:
initial study?
Gold standard?
Ideal?
initial: CTA
Gold standard: conventional angiography
Do both at same time in limb ischemia
PAD Tx? (3 courses)
- Risk factor modification
Smoking cessation, control DM and HTN, lose weight - Antithrombotic therapy long-term
ASA or Clopidogrel (Plavix) - Lipid-lowering therapy with at least a moderate intensity statin
Irrespective of LDL cholesterol level
Claudication Tx? (3)
Initial?
Rx? (1) and contraindication
Surg? (2)
- Initial: supervised exercise program
- Cilostazol (Pletal)
Contraindicated in ANY patients with CHF (↓survival). Patients with CAD have ↑ risk of angina & MI
3.Revascularization
For life threatening ischemia –or-
Patients with significant/disabling symptoms unresponsive to lifestyle modifications & medication
Stenting or bypass
What Rx is Contraindicated in ANY patients with CHF (↓survival)
Cilostazol
S/E of Cilostazol
s/e: headache, diarrhea, infection, rhinitis
A/N Foot Ulcers:
Location?
A: Toe Joints
N: Plantar Surface
A/N Foot Ulcers:
Appearance?
A: Irregular margins
Pale or necrotic base
N: ‘punched out’
Red base
A/N Foot Ulcers:
Ulcers w/in callus?
A: rare
N: yes
A/N Foot Ulcers:
Pain?
A: yes
N: No
A/N Foot Ulcers:
Deformity?
A: No
N: Often
A/N Foot Ulcers:
Skin Changes
A: Shiny, taunt
N: Waxy or shiny, poss pitting edema
A/N Foot Ulcers:
Reflexes?
A: present
N: absent
___ is a strong predictor of adverse CV outcomes (CHF risk equivalent)
PAD
PMH & P/E Predictors of progression to acute limb ischemia? (3)
- DM
- , ↑pack year smoking hx
- Lower ABI
Asssessment & Plan PAD
How to fix:
- PAD ->
- Type 2 Diabetes with CKD3b->
- HTN ->
- HLD ->
- Hypothyroidism->
- Tobacco use ->
- Obesity ->
Wells Pretest Probability for DVT (10)
HANG IN THERE!
- CA tx in last 6mo
- Paralysis/paresthesia or cast of BLE (stasis)
- Bedridden for 3d in last 4wks
OR
major surg in last 12wks. - Vein tenderness
- Swelling of ENTIRE leg
- UNILATERAL calf swelling >3cm
- UNILATERAL pitting edema
- prior DVT
- Collateral veins (compensation)
- Any other Dx makes more sense
Pretest Probability for DVT
D-dimer?
U/S?
Low->
Moderate->
High->
low: 0pts
D-dimer:
if NL-DONE
if (+)- U/S
Moderate: 1-2pts
HIGH SENSITIVITY D-dimer:
if NL-DONE
if (+)- U/S
High: 3-8pts (50-75%)
NO D-DIMER
DO U/S!
Wells Pretest probability for PE (7)
- DVT sx
- PE likely Dx
- Bedrest ≥3d
OR Surg in 4wks - Previous PE/DVT
- Hemoptysis (SOB pts)
- CA Tx in 6mo
- HR >100
Pretest Probability for PE (using Wells)
D-dimer?
CTPA?
Low->
Intermediate->
High->
Low: <2pts
Apply PERC
1. if pt fulfills ALL PERC-> DONE (NO D-dimer/CTA)
2. if 1 is not fulfilled-> D-Dimer
if D-dimer (+)-> CTPA
Intermediate: 2-6pts
D-dimer:
(+)-> CTPA
(-)-> DONE
High >6pts
DO CTPA
No need for D-Dimer!!
PERC (8)
- Age <50
- HR <100
- O2 Sat ≥95%
- No hemoptysis
- No estrogen use
- No prior DVT/PE
- No UNILATERAL leg swelling
- No surg/trauma req admission in 4wks
Key things that can cause an ↑ D-dimer
Surg Trauma NL pregnancy Sickle Cell Dz w/ vasoclusive episode ↑ age Afib CHF/CVD infection/sepsis/inflamm MI/CVA Acute limb ischemia preeclampsia thrombolytic agents AV malformations Liver/Renal dz
Test that is SENSITIVE and SPECIFIC for PE Dx
CTPA (with contrast)
