Skin Changes In Cardiopulmonary Disease DSA

Question 1

Distinguish arterial vs venous changes in skin based on presenting signs and symptoms. What suggests arterial occlusion?

Answer 1

There is white color to the foot compared with the other In arterial occlusion, the “6 P’s” reflect the loss of blood flow to the affected area, thus leading to amputation if no emergent intervention -Paresthesias -Perishing cold -Pulselessness -Pain -Paralysis -Pallor The area has such a different (not human) feel on palpation that it’s often described as waxy

Question 2

Distinguish arterial vs venous changes in skin based on presenting signs and symptoms. What suggests venous congestion?

Answer 2

Superficial varicosities – small irregular dark blue lines indicate venous congestion Edema – mild in this picture Both can indicate poor venous return due to incompetent valves in veins Systemic hypertension contributes to poor venous return

Question 3

What is stasis dermatitis?

Answer 3

Reddish/Purplish/Brownish discoloration in skin develops over time Due to hemosiderin deposits staining the skin from red cell breakdown Occurs with decrease flow or “stasis” on venous side of circulation

Question 4

What is cellulitis?

Answer 4

Cellulitis – inflammation of skin and subcutaneous tissue – most often infectious Marked erythema Increased warmth Increased swelling Sometimes skin weeping without any apparent open sores

Question 5

What are the characteristics of advanced stasis dermatitis?

Answer 5

Skin thickened Firm to touch “Brawny edema” term often used to describe if swollen

Question 6

What are janeway lesions?

Answer 6

Irregular macules Soles, palms Non-tender Days - weeks BACTERIAL ENDOCARDITIS

Question 7

What are Osler’s nodes?

Answer 7

Nodules 1 mm – over 1 cm Fingers and toes, thenar and hypothenar eminence Tender Hours to days BACTERIAL ENDOCARDITIS

Question 8

What are splinter hemorrhages?

Answer 8

Microemboli produced from valvular pathology Periphery of nail bed More likely due to nail trauma if isolated or minimal involvement BACTERIAL ENDOCARDITIS

Question 9

What is xanthelasma?

Answer 9

Associated with hyperlipidemia Xanthelasma palpebrum = xanthomas on the eyelids Most common form of Xanthoma Can occur multiple other locations Lipid laden deposits

Question 10

What is clubbing?

Answer 10

This is chronic Lung disease most common association Platelet and endothelial growth factors may contribute to process Peripheral hypoxia may be part of trigger

Question 11

List acute changes in the skin that may suggest a cardio pulmonary problem

Answer 11

Osler’s nodes splinter hemorrhage Janeway lesions

Question 12

List chronic changes in the skin that may suggest a cardio pulmonary problem

Answer 12

Increased varicosities and edema Stasis Dermatitis Cellulitis Xanthelasma Clubbing

Question 13

What are eruptive xanthomas?

Answer 13

Associated with hyperlipidemia Xanthomas NOT seen in all patients with hyperlipidemia When observed, check cholesterol panel and verify other appropriate screening done annually Arrow indicates “umbilicated lesion” (dent in center of papule) – can look like molluscum contagiosum (viral infection)

Question 14

Determine risk factors for peripheral and central vascular disease

Answer 14

Dietary indiscretion – high salt, high fat, low fiber Hypertension Hyperlipidemia Diabetes Alcohol excess – contributes to cardiomyopathy and mitochondrial and endothelial dysfunction - additionally the dehydrating effects of alcohol consumption causes sludging or congestion/impairment of optimum blood flow in the vasculature Family History: Genetic predisposition eg Buerger’s disease

Question 15

Formulate a plan to implement Therapeutic Lifestyle Changes (tlc) to modify symptoms and slow progression

Answer 15

Smoking cessation Exercise Weight loss Support hose (stockings) Compression hose (stockings) Psychosocial support – multidisciplinary approach Follow-up regularly (eg every 3 months) to monitor for changes and encourage patient, and re-enforce/revise plan of care

Question 16

In regards to implementing some TLC, how does one prioritize step-wise behavior modification to optimize patient success?

Answer 16

Work with patient to decide which TLC (Therapeutic Lifestyle Change) would be the most manageable to start of the previous list May need multiple measures, including meds, but involving patient with the decision process helps assure their engagement Consider social service, physical therapy, occupational therapy, counselling, dietary education to maximize patient’s information base and engagement in plan Follow-up to modify as needed Set realistic goals

Question 17

What should be on the plan to prevent complications for those with CP related issues?

Answer 17

***Note this looks suspiciously like the TLC info with meds added Smoking cessation Exercise Weight loss Support hose (stockings) Compression hose (stockings) Psychosocial support Follow-up regularly (eg every 3 months) to monitor for changes and encourage patient, and re-enforce/revise plan of care Medications –Modify risk factors: Hypertension, Lipids, Glucose, –Proteinuria –Direct vasodilators

Question 18

In regards to assessing a patients with chronic pulmonary disease, what is the difference between a “blue bloater” and a “pink puffer?”

Answer 18

Question 19

Determine symptoms suggesting claudication
Differentiating neurogenic from vascular claudication.

Answer 19