Exam 1 - Peripheral vascular dz packet Flashcards
1
Q
Possible S/Sx of arterial occlusion in an extremity? (8)
A
Numbness, tingling, pain, weakness, coldness, pallor or “mottling” of skin, motor/sensory/reflex alterations, decreased pulse amplitude distal to occlusion
2
Q
What is “dusky cyanosis”?
A
Mixed rubor and cyanosis
3
Q
What is an embolus?
A
Mass, such as detached blood clot/foreign body/air bubble that travels through bloodstream
4
Q
What is an embolism?
A
embolus that lodges so as to obstruct or occlude a blood vessel
5
Q
What are emboli most often associated with?
A
Ischemic heart disease
6
Q
Where do cardiogenic emboli tend to lodge?
A
In the bifurcations of major arteries
7
Q
Where do the majority of emboli lodge?
A
Aortic bifurcation and larger arteries of lower extremities
8
Q
What are splinter hemorrhages indicative of?
A
Infective endocarditis
9
Q
What is a thrombus?
A
Blood clot formed within a blood vessel that remains attached to its place of origin
10
Q
Where do thrombi usually occur?
A
At sites narrowed by atherosclerotic plaque
11
Q
What are acute arterial thromboses often precipitated by?
A
Inflammation of the arterial wall
12
Q
What does Peripheral arterial disease (PAD) refer to?
A
arterial insufficiency in the lower extremities
13
Q
What is PAD usually due to?
A
atherosclerotic plaque
14
Q
Who is PAD much more common in?
A
Diabetics
15
Q
Causes of subclavian artery occlusion? (4)
A
- cardiogenic emboli 2. thrombus formation 3. arterial thoracic outlet syndrome 4. subclavian steal syndrome
16
Q
How common is arterial thoracic outlet syndrome?
A
Relatively uncommon (1%)
17
Q
What is a huge problem with artertial thoracic outlet syndrome?
A
False positives
18
Q
What is subclavian steal syndrome due to?
A
Usually due to acquired atherosclerotic occlusion of subclavian artery PROXIMAL to vertebral artery
19
Q
How does subclavian steal syndrome usually manifest?
A
As an exercise-induced “theft” of blood from the ipsilateral vertebral artery
20
Q
S/Sx of subclavian steal syndrome?
A
involved arm SBP is >20 mmHg lower, decreased pulse amplitude, “claudication” symptoms of weakness/fatigability/pain
21
Q
What does coarctation of the aorta lead to?
A
Upper extremity hypertension and lower extremity hypotension/lower extremity “pulse lag”
22
Q
What is “infantile” aortic coarctation?
A
Pre-ductal
23
Q
What is “adult” aortic coarctation?
A
Post-ductal
24
Q
Common first symptoms of aortic coarctation?
A
Decreased exercise tolerance and easy fatigability
25
How often do abdominal aortic aneurysms occur in the US?
5 to 8 % of people over 60
26
How do most pts with AAA present?
Asymptomatic
27
What is the normal diameter of infrarenal/supraumbilical aorta?
2 cm
28
What is the normal aortic pulsation?
Brief, succinct, short duration
29
What is the only physical exam procedure with demonstrated value in the detection of AAAs?
Palpation
30
What is the anticipated increase in aortic diameter with increasing age/male gender/increasing body mass?
>2cm but < 3 cm
31
Technical definition of AAA?
infrarenal aorta that is > 3 cm in diameter
32
When should there be clinical concern regarding an AAA?
Aneurysm > 4 cm in diameter
33
How many patients are AAAs diagnosed in before rupture?
One-third
34
Non-modifiable risk factors for AAA?(3)
Advancing age, male gender, ethnicity
35
Modifiable risk factors for AAA? (3)
Cigarette smoking, HTN, Atherosclerotic diseases
36
Potential AAA complications? (4)
1. "extension" of aneurysm to renal or common iliacs 2. acute lower extremity arterial insufficiency 3. "impending" rupture (expansion or controlled bleed) 4. Overt rupture (hemorrhage, shock, death)
37
What are significant findings on auscultation of abdominal aorta?
Systolic bruits
38
are abdominal bruits well-localized?
No
39
How would you detect an AAA by palpation?
expansile, pulsatile mass
40
What is an abnormal aneurysmal pulsation?
Prolonged, diffuse, long duration
41
What 2 factors affect the ability to examine a pt for suspected AAA?
Size of pt, size of AAA
42
How much does an AAA typically grow in a year?
0.2-0.8 cm in diameter per year
43
How common is rupture of AAA under 4 cm?
Uncommon
44
How common is rupture of AAA > 7 cm?
19-25% annual rate of rupture
45
What is the modality of choice for monitoring smaller aneurysms?
Diagnostic ultrasound
46
What do the symptoms and time-line of an AAA rupture depend on?
type of rupture
47
S/Sx of "impending" rupture? (4)
1. flank pain of sudden onset (may mimic kidney stone) 2. back pain of sudden onset (may mimic herniated disc) 3. abdominal pain of sudden onset 4. pain usually unrelieved by changes in position
48
S/Sx of "frank" rupture?
shock and death
49
What do acute/frank ruptures almost always follow?
Slow bleed/"impending" rupture
50
What is PAD most commonly associated with?
Atherosclerosis
51
What does PAD indicate a high risk for?
Cardiovascular morbidity and mortality
52
Non-modifiable risk factors for PAD? (2)
Being over 60, male gender
53
Modifiable risk factors for PAD? (3)
1. Smoking 2. HTN 3. Diabetes
54
How much more common is PAD in diabetics than non-diabetics?
3-5 times more common
55
What are the "classic" findings for PAD based on?
Unilateral disease
56
In PAD, which is more common, bilateral aortoiliac "segment" or unilateral femorpopliteal "segment"?
unilateral femoropopliteal segment
57
In PAD, is bilateral disease progressive or not?
Most often progressive
58
In PAD, is unilateral disease progressive or not?
Less often progressive
59
Site of claudication in unilateral PAD?
Calf muscles and foot
60
Which pulses are absent in unilateral PAD?
Popliteal and foot pulses
61
Trophic changes in PAD (bilateral vs unilateral)?
Bilateral = minimal trophic changes unilateral = distinct changes
62
Findings on adjunct procedures with unilateral PAD?
Delayed venous filling, dependent rubor, etc
63
What is an essential component of treatment for PAD?
Risk factor modification
64
How many pts have "asymptomatic" PAD?
50%
65
What type of leg pain do PAD pts have on exertion?
"non-claudication" leg pain
66
How many PAD pts have "peripheral arterial occlusive disease" and claudication?
40%
67
What is the "classic" indicator of symptomatic PAD?
Intermittent claudication
68
Where is ischemic pain classically seen in PAD?
the calf
69
What does the distribution of symptoms of PAD depend on?
level of occlusion
70
Typical history/pattern of PAD?
Fixed threshold distance, short tolerance distance, brief refractory period
71
What is fixed threshold distance?
onset of pain after walking a short, PREDICTABLE distance
72
What is short tolerance distance?
Pt cannot continue walking due to pain
73
What is brief refractory period?
pain decreases almost as soon as pt rests
74
What type of atherosclerosis does intermittent claudication indicate?
"high grade" atherosclerosis
75
What percentage of PAD pts have critical leg ischemia?
10%
76
What do rest pain, ulcers, and gangrene indicate in PAD pts?
very advanced disease
77
3 indicators of PAD in symptomatic leg?
1. absence of dorsal pedal and post tib pulses 2. wounds/sores on foot 3. presence of asymmetric foot coolness
78
What is neurogenic claudication?
BILATERAL leg heaviness/tingling makes pt want to stop walking
79
How is neurogenic claudication different from PAD?
bilateral, pulses usually intact, threshold distance varies day to day, tolerance distance varies, refractory period varies
80
PAD exam: what should normal venous filling time be?
<20 seconds
81
PAD exam: what should normal capillary refill time be?
<5 seconds
82
What is the ankle-arm index (AAI)?
Ankle BP / Arm BP
83
Normal AAI range?
1.0-1.3
84
Where do most pts with arterial intermittent claudication have AAIs?
0.5-0.8
85
What does AAI correlate to?
Distance pt can walk symptom-free
86
How far can pt walk with AAI of 0.6-0.8?
1-2 blocks
87
How far can pt walk with AAI of 0.4-0.6?
Less than one block
88
How far can pt walk with AAI of <0.4?
Rest pain, arterial ulcers, gangrene = advanced disease
89
What is the most important risk factor for PAD?
smoking
90
What is the most effective tx of PAD?
exercise training
91
What is Raynaud's phenomenon?
reversible vasospastic ischemia of peripheral arterioles, most often seen in fingers
92
Classic tri-phasic color change of Raynauds?
Pallor, cyanosis, rubor
93
How many color changes are seen in the common presentation of Raynauds?
At least 2
94
How defined is the area involved in Raynauds?
Well defined/well demarcated
95
Where does demarcation of Raynauds usually occur?
Joint lines
96
What is the vasospasm/pallor/cyanosis of Raynauds usually accompanied by?
numbness/tingling
97
What does rubor indicate in Raynauds?
Circulation has been restored
98
Is Raynauds a primary or secondary condition?
Can be either
99
What is primary raynauds?
Idiopathic vasospasm
100
Which hand is usually affected with primary raynauds?
BOTH
101
How long do primary attacks of Raynaud's last?
30-60 minutes
102
Which gender is Raynauds more common in?
Women
103
Common triggers of Raynauds? (3)
1. cold environments 2. mental stress 3. smoking
104
What percentage of primary Raynauds pts respond to conservative care?
90%
105
What should primary Raynaud's pts be monitored for? (4)
1. connective tissue diseases 2. capillary nailfold changes 3. telangectasia 4. rashes
106
What is a possible treatment for Raynauds that may lower number of attacks?
Gingko biloba
107
What should you consider if a Raynaud's pt has changes in the nail fold?
autoimmune diseases
108
Is secondary Raynauds unilateral or bilateral?
More often unilateral
109
What is secondary Raynauds often associated with?
autoimmune diseases
110
What syndromes may predispose to Raynauds, but rarely lead to nail fold changes? (2)
carpal tunnel syndrome or thoracic outlet syndrome
111
What should you look for in a digit exam for Raynauds pts? (4)
1. telangiectasia 2. persistant cyanosis or ulcers 3. sclerodactyly 4. peripheral pulses
112
What is the third most common CV disease in the US?
Deep vein thrombosis
113
What can DVT lead to if untreated?
pulmonary embolism
114
What is Virchow's triad?
1. venous stasis 2. hypercoagulability 3. vessel wall inflammation
115
Why is Virchow's triad important?
all known clinical risk factors for DVT/pulmonary emboli have their basis in one or more elements of the triad
116
What is venous thrombophlebitis?
secondary inflammatory changes to vein
117
What can thrombophlebitis lead to?
Deformation of the venous valves
118
Classic risk factors for DVT? (4)
1. Family Hx 2. venous stasis 3. Recent major surgery or trauma 4. active cancer/chemotherapy
119
Why is DVT hard to diagnose?
Asymptomatic in early stages
120
Which vein is involved in 80% of pts with confirmed DVT?
popliteal vein
121
Are proximal or distal DVTs more threatening?
Proximal have much higher incidence of pulmonary embolism
122
Which vein is involved in about 20% of DVT pts?
Posterior tibial vein
123
What are commonly reported findings in cases of suspected DVT? (6)
pain, swelling, pitting edema, warmth, dilated superficial veins, erythema
124
What should you look for in a DVT exam? (5)
1. thigh swelling 2. asymmetric calf swelling 3. superficial venous dilation 4. asymmetric skin warmth 5. Homan's sign
125
What is Well's decision making tool for DVT?
Assign one point for each clinical characteristic. Subtract 2 points if there's an alternative diagnosis that is as likely.
126
What score (using Wells decision tool) indicates likely DVT?
>2
127
Potential complications of DVT? (3)
1. chronic venous insufficiency 2. recurrence of DVT 3. pulmonary embolism
128
What is the second most common cause of sudden, unexpected natural death at any age?
pulmonary embolism
129
Classic triad of S/Sx of pulmonary embolism?
1. hemoptysis 2. dyspnea 3. chest pain
130
What percentage of PE pts show the triad of symptoms?
20%
131
Possible DVT differentials? (3)
1. gastrocnemius hematoma 2. acute cellulitis 3. Baker's cyst
132
What are two classic but unreliable exam procedures for DVT?
Mose's sign, Homan's sign
