PVS Flashcards
Transverse depressions of the nail plates, usually bilateral, resulting from temporary disruption of the proximal nail growth
beaus line - peripheral ischemia
a. Painless separation if the whitened opaque nail plate from the pinker translucent nail bed
b. Local causes: trauma, psoriasis, fungal infection, allergic rxn
c. Systemic causes: peripheral ischemia, anemia, DM, hyperthyroid, syphilis
onycholysis - raynauds
smooth and rounded contour +2
normal pulse
small and weak +1
decreased CO
pulsus parvus
weak and delayed pulse
aortic stenosis
pulsus parvus et tardus
increased pulse pressure, rapid,brief peak +3, increase SV, AR, bradycardia, AV fistulas
bounding pulse
alternate beats due to changing systolic pressure
LHF
pulsus alternans
two beats occurring in rapid succession, followed by a pause (normal beating alternating with a premature contraction)
pulsus bigeminus
two palpable peaks (1 beat with 2 peaks)
hypertrophic obstructive cardiomyopathy
bisferiens pulse
- exaggeration of the normal variation in the pulse during inspiration
a. Decreased systolic > 10 on quiet inspiration
COPD exacerbations, cardiac tamponade, constrictive pericarditis, sleep apnea
pulsus paradoxus
Pt makes tight fist, compress radial and ulnar arteries, pt opens hand, palm is pale, release ulnar artery, palm flushes in 3-5 sec
Allens test
smaller, red, purple, blue vessels < 1mm, non palpable – central dilated arteriole surrounded by small veins carrying away the free flowing blood
telangiectasia
cyanotic discoloration – blue toe syndrome – impending necrosis
Atheroembolism
dependent rubor, thin, shiny, atrophic skin; loss of hair over foot and toes; nails thickened
arterial disorder
stasis dermatitis; thickening of skin brown discoloration; ulcer
venous disorder
i. Episodic m. ischemia induced by exercise d/t obstruction of lg or med sized artery by atherosclerosis
ii. Usually calf, butt, hip, thigh, foot
iii. Brief, pain forces pt to rest, severe crampy pain
iv. Agg by exercise, alleviated with rest and pain stops in 1-3 minutes
v. Local fatigue, numbness, diminished pulses, signs of insufficient
intermittent claudication -atherosclerosis
i. Severe continuous ache in butt, thigh, calf, foot
ii. Relieved by hanging affected leg off side of bed
iii. Pallor, coldness, fatigue, numbness, ulcers
rest pain - atherosclerosis
looking for low velocity flow through the artery
duplex doppler for PAD
a. Sudden embolism or thrombosis
b. Distal pain – usually foot and leg
c. Sudden onset – 6 Ps pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
acute limb ischemia
a. Claudication
b. Pallor on elevation, dusky red on dependence
c. Thin, shiny, atrophic skin, hair loss, thickened and ridged nails
d. Gangrene possible
e. Ulcerations on toes and or feet
f. Temp cold
g. Pulses decreased or absent
h. No edema, muscle atrophy
i. ABI >.9
chronic arterial insufficiency
a. Atherosclerosis of abdominal aorta just above site of bifurcation @ L4
b. Claudication of calf muscle, then thigh, hip, butt, in more severe
c. Impotence/ erectile dysfunction
d. Diminished pulses in lower limb
e. Dx: duplex Doppler
f. DDx: Osteoarthritis of the hips and knees – normal ABI – pain does not disappear at rest; Sciatica – normal ABI – pain not correlated with exertion
LeRiche syndrome - aorta-iliac occlusive disorder -AIOD
a. Age > 65, white male, smoking, HTN, CAD, FxHx, marfan syndrome, trauma
b. Thumb palm sign*
c. Failure of the structural proteins of the aorta
i. Unruptured: asymptomatic
ii. Ruptured: ripping chest pain radiating to back; dyspnea; PE: hypotension, tachycardia, AR murmur
d. Non tender, pulsatile abdominal mass above the umbilicus
e. Grey turner sign at flanks; cullens sign at center
f. Dx: chest x ray, abdominal ultrasound, CT or MRI with contrast
aortic aneurysm
a. Inflammation and thrombotic occlusions of smooth artery and vein – occurring smokers
b. Non-atherosclerotic; Segmental inflammation
c. Intermittent claudication – arch of foot and hands; Rest pain in fingers or toes
d. Brief recurrent ic; Chronic persistent, worse at night rp
e. AG: exercise; AL: rest; permanent cessation of smoking – helps both kinds of pain
f. 20 -40 y/o smokers; distal coldness, sweating, numbness, cyanosis, paresthesia; ulceration & gangrene at fingertips; migratory thrombophlebitis
g. angiogram – looking for smooth tapering lesion in distal vessels
thromboangitis obliterans - burgers disorder
a. Primary – episodic spasm of small artery – no vascular occlusion
b. Secondary – to other conditions ex: collagen vascular dz, artery occlusion, trauma, drugs
c. Distal fingers, pain usually not prominent unless fingertips ulcers develop
d. Numbness and tingling common
e. Ag: exposure to cold, emotional upset; AL: warm environment, smoking cessation
f. Color change: distal fingers – white blue red
g. Blood tests: ESR, ANA, C3
raynauds
a. Entrapment of popliteal artery by medial head of gastrocnemius muscle
b. Unilateral claudication
c. Hx: intermittent, exercise – induced
d. May occur with thrombosis or embolism
popliteal artery entrapment syndrome
a. Pulsatile mass
b. Limb ischemia secondary to thrombosis or embolism
c. Dx: Doppler
d. DDx: bakers cyst – non pulsatile mass, knee pain, stiffness, swelling
popliteal artery aneurysm
detects stenosis in major blood vessels in legs
R ABI = higher R ankle/ higher brachial (R or L)
L ABI = higher L ankle/ higher brachial (R or L)
ankle brachial index
a. Raise both legs for 1 min until maximal pallor of the feet develops
b. Ask pt to sit with feet hanging off, compare
i. Return to pink <10 sec
ii. Filling of veins ~15 sec
iii. Look for unusual rubor – dusky redness
postural changes test
a. Abrupt dorsiflexion of the patients foot at the ankle while the knee is flexed to 90 degrees
testing for DVT
homans test
a. Incompetent venous valves, venous obstruction
b. Superficial leg veins – great saphenous + tributaries; posterior saphenous
c. Leg pain – aching, burning, AG: standing, relieved by elevation; dilated tortuous bluish green veins
varicose veins
a. F>M
b. Virchow’s triad: hypercoagulability, injury, venous stasis
c. Lower limb: great saphenous vein
d. Leg pain, possible fever, erythema, tenderness, induration- nodular cord along vein, swelling
e. DVT 20%
f. Dx: Doppler – lack compressibility of vein
superficial thrombophlebitis
a. Blood clot in deep veins
b. Virchow triad
c. Popliteal/ superficial femoral vein
d. LE pain and swelling, possible fever, LE erythema, calf tenderness, homan sign – 50% of cases
e. Dx: compression ultrasound with Doppler - + study
f. Incompressibility, clot formation
g. D-dimer assay – high sensitivity, low specificity coagulation profile
deep vein thrombosis
a. Bilateral LE edema with dilated, visible superficial abdominal veins
b. Tumor: renal cell carcinoma
c. Extrinsic compression
d. Hematoma or trauma
e. Iatrogenic: venous catheter, pacemaker
inferior vena caval thrombosis
a. Effort thrombosis
b. UE: heaviness and swelling; diffuse aching pain, cyanosis
c. Dilated veins in chest and UE
d. Dx: Doppler
axillary subclavian vein thrombosis
a. Often painful
b. normal color or brown pigment
c. stasis dermatitis, excoriation, lichenification
d. ulcers medial side of ankle
e. no gangrene
f. normal temp, normal pulse, edema present
chronic venous insufficiency
a. Migratory thrombophlebitis
b. Intermittent superficial venous thrombosis at unusual site – arms, chest
c. Pancreatic cancer: inc age, heavy smoker, abdomen pain, weight loss, jaundice
d. Assoc. with malignancy of pancreas
e. Dx: CT of abdomen
trousseaus syndrome - paraneoplastic syndrome
a. Obstruction of the SVC impedes venous return
b. Edema of the neck, face, arms
c. Dyspnea, cough, headache, dizziness
d. Bending over or lying down accentuates symptoms
e. Dx: chest x ray
superior vena cava syndrome
a. Congenital: cutaneous birthmark at an early age with no history of trauma
i. Hypertrophy, sweating and hypertrichosis in affected areas
b. Acquired: trauma or hemodialysis
c. Dx: ultrasound and contrast angiography
d. Assoc. Localized murmur or thrill; branham sign: slowing of the pulse rat with compression proximal to the AVF; Visceral AVMs: hematuria, hematemesis, hemoptysis, melena
AVF
red streaks on skin, following lymph nodes; increase WBCs with left shift
lymphangitis
a. Painless, persistent, non-pitting edema, seen in young women
b. UE or LE
c. Swelling without ulceration, edema – indurated, hard, non-pitting in later stages
lymphedema
a. Pressure build up from direct trauma
b. Excruciating pain, pain increase on passive stretch, rapidly increasing and tense swelling, paresthesia
compartment syndrome
a. Non-purulent
i. deep dermis, slowly spreading rash with flat, indistinct edges + warmth, tenderness, indolent
b. Purulent: purulent drainage
c. leukocytosis – increase neutrophils
d. Fever, localized pain, redness, swelling + regional lymphadenopathy
cellulitis
a. Delayed hypersensitivity – sarcoidosis
b. Painful subcutaneous, bilateral anterior led nodules
erythema nodsum
