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PCM I Exam II > Lymphatic and peripheral exam > Flashcards

Lymphatic and peripheral exam Flashcards

1
Q

What are components of inspection to be on the look out for?

A

•Color
–Paleness =lack of arterial supply
–Blue = lack of oxygenation
–Purple = venous congestion
–Brown or Rust colored = hemoglobin pigmentation
–In darker skinned people look at the soles of the feet
•Edema
–Measure circumference and height of edema
–Note and grade pitting
•Presence of Hair
•Ulceration
•Swollen veins

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2
Q

What are the characteristics we may observe upon palpation?

A

•Skin Temperature
–Hot, Cold, or Normal
•Skin Texture
–Smooth or Rough
–Thickened or thinning
•Edema is usually non-pitting
•Grade pulses
•Thrill is turbulent flow through an artery consistent with partial obstruction
•Lymph nodes-note characteristics

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3
Q

What are the special tests we talked about?

A
  • Allen’s
  • Ankle/brachial index
  • Postural color change
  • Homan’s sign
  • Venous valve competency
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4
Q

Where do we find these pulses?
–Radial
–Brachial

–Dorsalis Pedis
–Posterior tibial

A

–Radial on radial side of wrist
–Brachial is medial to biceps tendon
–Dorsalis Pedis is lateral to the extensor hallucis longus
–Posterior tibial is poster to the medial malleolus

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5
Q

Location of these pulses?

  • popliteal
  • femoral
  • carotid
A

–Popliteal is posterior to the knee in the skin crease
–Femoral is inferior to the inguinal ligament in the inguinal crease
–Carotid is medial to sternal head of the sternocleidomastoid muscle

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6
Q

How do we grade pulses?

A

Always include a numerator and denominator, since different scales can be used.

•Strength-Usually graded on a scale of 3, i.e. 2/3 but the scale may be on a scale of 4

0 Unable to palpate

1 Diminished

2 Normal briskness (expected)

3 Bounding

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7
Q

What are the characteristics of pulses we need to assess?

A

Regularity, impulse character, symmetry between sides

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8
Q

What arteries do we auscultate?

What are we listening for? How should we do it?

A

–Carotid
•Have patient hold breath
–Temporal
–Aorta
–Renal
–Iliac (hard to hear)

  • Bruit is the sound of turbulent flow through an artery consistent with partial obstruction
  • Best heard with the bell
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9
Q

What sound does a normal artery make?

A

No sound, due to laminar flow.

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10
Q

What does ankle-brachial index test?

A

Indicates peripheral artery disease

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11
Q

What is a normal Ankle-brachial index finding?

A

Normal

A resting ankle-brachial index of 0.9 to 1.3 is normal and suggests no significant narrowing or blockage of blood flow.

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12
Q

What is an abnormal Ankle-brachial index finding?

A

Abnormal

A resting ankle-brachial index of less than 0.9 is abnormal. If the ABI is 0.41 to 0.9, there is mild to moderate peripheral arterial disease. If ABI is 0.4 or below, there is severe peripheral arterial disease.

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13
Q

Describe the Allen test

A

•Have the patient open and close the fist several times quickly, then will hold it closed tightly. Apply firm pressure over the radial and ulnar arteries. Ask the patient to open the hand slowly. Release the pressure on one of the arteries and observe the return of pink coloration of the hand. Repeat the process to test the collateral artery supply.

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14
Q

What test is shown here?

A

Allen Test

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15
Q

Describe the postural color change test

A
  • Tests for chronic peripheral arterial disease
  • With the patient lying on their back, elevate the affected extremity for at least 1 minute
  • If the color becomes pale, lower the extremity to watch for return of pinkness which should occur within 10 seconds
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16
Q

What is the common denominator in arterial disease?

A

Decreased arterial perfusion

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17
Q

What are the common symptoms of arterial disease?

(7)

A
  1. –Pain (Ischemic)
  2. –Coldness
  3. –Numbness
  4. –Hair loss (Chronic)
  5. –Color change (Chronic)
  6. –Loss of pulse
  7. –3 P’s-Pain, Pallor, Pulselessness
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18
Q

What are the three P’s?

A

Pain, Pallor, Pulselessness

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19
Q

Describe an acute arterial occlusion

A
  • Occlusion of the artery by embolus often a thromboembolus
  • Sudden onset of very severe extremity pain
  • Unilateral
  • Not aggravated by movement or position change
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20
Q

SSX and physical findings of an acute arterial occlusion?

A
  • Associated sx: Cold, weak, numb distally
  • Physical findings: Extremity is pallid, cool and pulseless
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21
Q

What is this an example of?

A

Acute Arterial Occlusion

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22
Q

What is this an example of?

A

Acute Arterial Occlusion

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23
Q

This is?

A

Acute Arterial Occlusion - End stage

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24
Q

Describe PAD

A

Peripheral Arterial Disease (PAD)

•Chronic inadequate arterial flow
•Intermittent claudication while walking, relived by rest
•Associated symptoms: muscle fatigue, numbness, cold feet
•Physical findings: decreased distal pulses, pallor on elevation, ulcers/gangrene
•Ankle Brachial Index is the ratio of the dorsal pedis and brachial arterial pressures (See Bates’ 10th Edition, Page 496)
•An index of less than 0.9 indicates PAD.
•

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25
Q

What is indicitive of Chronic PAD?

A

Rubor and Ischemic ulcer

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26
Q

What are we looking for on venous inspection?

A

–Varicosities
–Venous ulcers
–Hemosiderin deposits
–Edema
–Erythema

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27
Q

How is venous examination primarily accomplished?

A

Inspection

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28
Q

What are the two special tests associated with venous examination?

A

–Venous valve competency
–Homan’s

29
Q

What does homan’s test check for?

A

DVT in lower extremity (fairly innacurate)

30
Q

How does one do the Homan’s test?

A
31
Q

How does one perfrom a venous valve competency test?

A

•With patient supine, raise one leg as high off the table to 90 degrees and let the venous blood drain from the leg
•Occlude the great saphenous vein with one hand in the inner thigh and then lower the leg and ask the patient to stand up
•Watch for normal slow venous filling of the leg veins while maintaining pressure on the great saphenous vein from above
–If rapid filling occurs during this time there is incompetent valves of the communicating veins.
•After 20 seconds release the pressure on the great saphenous vein
–If sudden venous distension occurs , it indicates rapid venous filling and incompetent valves of the great saphenous vein.

32
Q

What are the conditions of Virchow’s triad?

A

–Stasis
–Hypercoagulability
–Endothelial injury

33
Q

What is a DVT?

A

•Clot formation in one of the larger veins usually the leg

34
Q

In Virchow’s triad, what is the most common way stasis occurs?

A

Airline travel

35
Q

In Virchow’s triad, what is the most common way hypercoagulability occurs?

A

Dehydration

36
Q

In Virchow’s triad, what is the most common way endothelial injury occurs?

A

Stretching the endothelium, causes breaks which leads to clotting.

37
Q

DVT can lead to what impact on the valve system?

A

Lead to breakdown of the valves.

38
Q

What symptoms are associated with DVT?

A

–Often painless, but may complain of discomfort secondary to swelling
–Almost always unilateral
–Not aggravated by movement, may be mild relief by non-weight bearing

39
Q

Key symptom of DVT?

A

Unilateral limb swelling

40
Q

Physical findings of DVT?

A

–Swelling
–Pitting edema
–Homan’s sign
–Discoloration of the distal limb from venous congestion

41
Q

What is shown here?

A

DVT

42
Q

Describe the consequences of Pulmonary Embolism

A

Major complication of DVT→ Large clot breaks off the leg and travels to lungs → Hypoxemia and necrosis of the lung→ Sudden death

43
Q

Describe superficial Thromophlebitis

A
  • Same mechanism as deep vein thrombophlebitis but in one of the smaller veins in the leg
  • Pain is a much more common complaint
  • Physical findings: may be redness and tenderness over the affected vein, usually much less swelling than with DVT
44
Q

What is going on here?

A

Superficial Thrombophlebitis, in area surrounding the papule

45
Q

What are vericose veins?

A

•Valves in veins of lower extremities become incompetent so that blood begins to pool in veins

46
Q

What are the SSX and physical findings of varicose veins?

A
  • Early the patient has few complaints and usually seeks care for cosmetic reasons. As the disease progresses, patients show signs of chronic venous insufficiency
  • Physical findings: engorged lower extremity veins very often the greater saphenous
47
Q

What is this condition? Is it dangerous?

A

Varicose Veins

Not dangerous, just ugly

48
Q

How does one map varicose veins?

A
  • Place your fingers on any two visible veins
  • Tap on the vein with one hand rapidly and feel with the other hand for a transmitted pressure wave
49
Q

Describe the pathways of venous disease.

A
50
Q

Describe chronic venous insufficiency

A
  • Regardless of the causes, elevated venous pressure is the common result
  • Higher than normal venous pressure in legs → damage to the valves→ higher venous pressures → further damage to valves
51
Q

What are some risk factors for chronic venous insufficiency?

A
  2. –Deep vein thrombosis (DVT)
  3. –Varicose veins or a family history of varicose veins
  4. –Obesity
  5. –Pregnancy
  6. –Extended periods of standing or sitting
  7. –Age over 50
52
Q

SSX of CVI?

A

•Symptoms
–Diffuse ache in legs
–Gradual onset over months
–Aggravated by prolonged standing
–Alleviated by elevation of the legs
•Signs
–Pitting edema
–Rust colored skin with chronic disease
–Thickened skin hair
–Moist reddened ulcers

53
Q

What is this condition? What 3 things do we see here sign wise?

A

CVI

54
Q

What is this?

A

Pitting edema

55
Q

On inspection what are we looking for in lymphatics?

A

–Erythema-commonly seen in lymphangitis
–Enlarged nodes-infiltration of the nodes by infection or malignancy
–Edema-Due to mechanical obstruction of lymph channels or infectious disease

56
Q

What are we looking for with palpation of lymphatics?

A

–Tenderness over lymphangitis
–Palpable nodes
–Non pitting edema

57
Q

Describe lymphedema

A
  • mph channel obstruction or damage
  • Gradual onset
  • Unilateral or bilateral dependingon cause
  • Aggravated by pressure on lymphatics
  • Alleviated by elevation and pressure release
  • Examination: non-pitting edema, thickened skin, often no pigmentation change
58
Q

What characteristics should we note in palpation of lymph nodes?

A

–Size
–Tenderness
–Firmness
–Mobility
–Borders

59
Q

Where are lymphadenopathies palpable?

A
  • Often palpable in children
  • More often palpable in cervical region in children
  • More often palpable in inguinal region in adults
  • More often palpable in cervical region in adult smokers
60
Q

What are characteristics of lymphadenopathy, benign disease?

A
  • Less than 1 cm
  • Tender
  • May be firm but not hard
  • Freely movable
  • Discreet borders
61
Q

What are characteristics of lymphadenopathy, malignant disease?

A
  • Greater than 1 cm
  • Non tender
  • Rock-hard
  • Fixed to surrounding tissue
  • Difficult to palpate borders
62
Q

Describe lympangitis

A
  • Localized bacterial infection of lymphatics
  • Acute onset
  • Usually secondary to skin injury
  • Associated symptoms: pain and fever
  • Physical findings: Tender red streaks in the skin, tender and enlarged lymph nodes.
63
Q

What is this?

A

Lymphangitis

64
Q

How do you identify pitting edma? What does pitting or non-pitting indicate?

A

•This is most easily determined by using a finger to put pressure on an edematous area. If there is a “pit” after you remove your finger, it is pitting edema.
–Pitting is usually fluid overload or a cardiac problem
Non pitting is usually a lymphatic problem

65
Q

What should we record regarding edema?

A

Location on the body, and depth of the pitting in mm

66
Q

How does one grade edema?

A

–To grade pitting edema apply gentle, firm pressure with the thumb for 5 seconds in a swollen area, (often the pretibial area). Upon release if an indentation remains, grade:
•Grade 1 = 2 mm pit and resolves quickly
•Grade 2 = 4 mm pit and resolves in less than 1 minute
•Grade 3 = 6 mm pit lasts from 1-2 minutes
•Grade 4 = 8 mm pit and lasts from 2- 5 minutes

67
Q

Describe cellulitis

A
  • Inflammation of the skin and/or subcutaneous tissues
  • Almost always a bacterial infection usually strep or staph
  • Acute onset
  • Usual presenting symptoms: pain, redness and warmth (dolor, rubor and calor)
  • Physical findings: well demarcated area that is exquisitely tender to palpation
  • Frequently accompanied by localized lymphadenopathy
68
Q

What is this? What should we note in the images?

A

Cellulitis

Note the Well demarcated advancing border of cellulitis.

PCM I Exam II (4 decks)

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