Peripheral Vascular Disease

Question 0

What are the characteristics of intermittent claudication?

Answer 0

Muscular aching or cramping
Located In major muscle masses (buttocks, thighs, calves)
Produced by walking, relieved by rest (never happens DURING rest)
Reproducible

Question 1

What are the six Ps that represent the classic presentations of acute arterial insufficiency?

Answer 1

Pulselessness
Pallor
Poikilothermia
Pain
Paresthesia Highest
Paralysis - most indicative Severity

Question 2

What is the pathophysiology of intermittent claudication?

Answer 2

Blood flow adequate to meet resting metabolic needs
Cannot increase blood flow during exercise due to occlusive disease
Inadequate blood flow during exercise, anaerobic glycolysis –> H+, lactate

Question 3

What are the characteristics of ischemic rest pain?

Answer 3

Numb, aching, constant pain
Forefoot, toes, metatarsal heads = distal circulation
Relieved by dependency, aggravated by elevation

Question 4

What is the pathophysiology of ischemic rest pain being improved with dependency?

Answer 4

Gravity causes slight increase in blood flow
Increase in venous pressure
Prolongs red cell residence time
Maximal O2 extraction

Question 5

What are the signs and symptoms of chronic arterial insufficiency?

Answer 5

Absent pulses
Decreased hair growth - foot, toes
Skin atrophy (thin, shiny)
Muscular atrophy (disuse)
Thickened nails 
Blanch on elevation
Dependent rubor (chronic dilation skin capillaries)
Slow venous refill (>10-15 sec)

Question 6

How do you record pulses in a patients chart?

Answer 6

+ indicates normal, palpable pulse
W indicates a weak pulse
- indicates pulse not palpable
D indicates nonpalpable is audible by Doppler
0 indicates not palpable OR detectable by Doppler - urgent intervention

Question 7

How can you feel the femoral pulse?

Answer 7

fingertips in depths of groin crease and palpate upwards towards inguinal ligament
Pulse found at midpoint of line between ASIS and pubic tubercle

Question 8

How can you feel the popliteal pulse?

Answer 8

Flex knee and make sure extremity relaxed
Meet fingertips behind knee and press deeply
Counter pressure with thumbs

Question 9

How can you feel the dorsalis pedis pulse?

Answer 9

Just lateral to extensor tendon of big toe

Absent in 10-15% of people

Question 10

How can you feel the posterior tibial pulse?

Answer 10

Halfway between most prominent portions of medial malleolus and calcaneus
Use pads of first three fingers
Gentle counter pressure with thumb

Question 11

What are some conditions confused with rest pain and how can you differentiate them?

Answer 11

Neuropathy - stocking distribution, sensation, burning
Gout - inflammation, increased uric acid
Metatarsalgia - pain on joint motion
Trauma - history, pain on squeezing

Question 12

What is the rupture triad of AAA?

Answer 12

Pain (back, flank, and/or abdominal)
Pulsatile mass
Shock (hypotension)

Question 13

How can you feel and determine the size of the aorta on physical exam?

Answer 13

Patient has knees up, arms at side
Stand to right and use finger pads
Deep palpation at or just above umbilicus - where bifurcation is
Obese individual - use line drawn between iliac crests
Normal aorta is about 2 cm

Question 14

What are transient ischemic attacks?

Answer 14

Focal neurologic deficit in carotid or vertebral-basilar distribution
Key distinction from stroke - lasts less than 24 hours (most 1 or 2)
Complete recovery
Diagnosed by history

Question 15

What we signs and symptoms of TIAs in right carotid, left carotid, or vertebral-basilar arteries?

Answer 15

Right - left body motor and sensory deficits, upper body more affected
Left - right body motor and sensory, expressive aphasia
Vertebral basilar - bilateral motor and sensory, diplopia, cerebellar symptoms

Question 16

What is amaurosis fugax?

Answer 16

Transient, monocular visual disturbance
Lasts seconds to minutes, full recovery
May be total blindness, but usually ascending or descending curtain

Question 17

What is the pathophysiologic basis of ischemia with carotid bifurcation plaque?

Answer 17

Atheroembolism
Platelet fibrin emboli
Carotid thrombosis
Severe stenosis –> reduced flows

Question 18

What is abnormal when feeling bilateral upper extremity blood pressures?

Answer 18

Greater than 15-20 mm Hg difference

Question 19

What finding on neck pulses is indicative of obstruction of common carotids or innominate?

Answer 19

Asymmetry of neck pulses

Question 20

What findings in a bruit can differentiate between bifurcation occlusive disease and other causes?

Answer 20

Bruit becomes loser as one progresses down scm - most likely from chest
Bruit lessens in intensity as one progresses down scm - most likely from carotid bifurcation

Question 21

Why is listening for bruits not the best indication?

Answer 21

Poor correlation between intensity and severity of stenosis
Very advanced (>80%) stenosis wouldn't produce bruit

Question 22

What is the risk for amputation with claudication, rest pain, and tissue loss?

Answer 22

Claudication - 5% at 5 yrs
Rest pain - 50% at 1 yr
Tissue loss - 75% at 1 yr

Question 23

What size generally denotes the classification of “aneurysm”?

Answer 23

1.5x the normal vessel size

Question 24

What is a hollenhorst plaque?

Answer 24

Shiny gold refractive object lodged at bifurcations of retinal artery branches
Neurologic exam should be carried out

Question 25

What is the risk for stroke in symptomatic vs asymptomatic patients with carotid occlusive diseases?

Answer 25

Symptomatic - 26% at 2 yrs if stenosis >70% without repair

Asymptomatic - 2% per year risk of stroke or death without repair