Vascular System

Question 1

injury to vascular endothelial cells

Answer 1

provokes thrombus formation, atheromas, and the vascular lesions of hypertension

Question 2

Atheroma

Answer 2

begins in the intima as lipid-filled foam cells and then becomes fatty streaks

Question 3

Complex atheromas

Answer 3

thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken the underlying media. They have a soft lipid core and a fibrous cap of smooth muscle cells and a collagen-rich matrix. Plaque rupture may precede thrombosis

Question 4

Accumulation of interstitial fluid termed edema

Answer 4

due to lymphatic dysfunction or disturbances in hydrostatic or osmotic forces that disturb the equilibrium of the fluid exchange in the capillary bed

Question 5

An expanding hematoma from abdominal aortic aneurysm (AAA)

Answer 5

may cause symptoms by compressing the bowel, aortic branch arteries, or the ulcers

Question 6

Peripheral arterial disease (PAD)

Answer 6

stenotic, occlusive, and aneurysmal disease of the aorta, its visceral arterial branches, and the arteries of the lower extremities, exclusive of the coronary arteries

Question 7

Atherosclerotic PAD

Answer 7

Symptomatic limb ischemia with exertion.

Question 8

Intermittent claudication

Answer 8

any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes

Question 9

Neurogenic claudication

Answer 9

pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs,lower legs, or feet

Question 10

Spinal stenosis (Likelihood ratio 7.4 of neurogenic claudication)

Answer 10

If the pain from neurogenic claudication is relieved by sitting

Question 11

Likelihood ratio over 6 of neurogenic claudication

Answer 11

If the pain from neurogenic claudication is relieved by bending forward or if bilateral buttock or leg pain is present

Question 12

Hair loss over the anterior tibiae

Answer 12

due to decreased arterial perfusion

Question 13

Dry or brown-black ulcers

Answer 13

due to gangrene

Question 14

PAD “warning signs”

Answer 14

1. fatigue, aching, numbness, or pain that limits walking or exertion in the legs; if present, ID the location. Ask also about erectile dysfunction 2. any poorly healing or non-healing wounds of the legs or feet 3. any pain present when at rest in the lower leg or foot and changes when standing or supine 4. abdominal pain after meals and associated “food fear” and weight loss 5. Any first-degree relatives with an abdominal aortic aneurysm

Question 15

Symptom location suggests the site of arterial ischemia

Answer 15

1. buttock, hip - aortoiliac 2. erectile dysfunction - illiac-pudendal 3. thigh - common femoral or aortoiliac 4. upper calf - superficial femoral 5. lower calf - popliteal 6. foot - tibial or peroneal

Question 16

Abdominal pain, “food fear,” and weight loss

Answer 16

suggests intestinal ischemia of the celiac or superior or inferior mesenteric arteries

Question 17

lymphedema of the arm and hand

Answer 17

may follow axillary node dissection and radiation therapy

Question 18

Prominent veins in an edematous arm

Answer 18

suggest venous obstruction

Question 19

Raynaud’s disease

Answer 19

wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers

Question 20

if an artery is widely dilated

Answer 20

aneurysmal

Question 21

bounding carotid, radial and femoral pulses

Answer 21

aortic insufficiency

Question 22

arterial occlusion from atherosclerosis or embolism

Answer 22

asymmetric diminished pulses

Question 23

enlarged epitrochlear node

Answer 23

local or distal infection, or generalized lymphadenopathy

Question 24

an inguinal mass suspicious for an incarcerated hernia

Answer 24

often diagnosed as AAA at surgery

Question 25

warmth and redness over calf

Answer 25

cellulitis

Question 26

Lymphadenopathy

Answer 26

enlargement of the nodes, with or without tenderness

Question 27

Distinguish between local and generalized lymphadenopathy

Answer 27

local - finding either a causative lesion in the drainage area; generalized - enlarged nodes in at least two other noncontiguous lymph node regions

Question 28

A diminished or absent pulse

Answer 28

makes partial or complete proximal occlusion 10 times more likely

Question 29

If the occlusion is at the aortic or iliac level

Answer 29

all pulses distal to the occlusion are typically affected

Question 30

Chronic arterial occlusion, usually from atherosclerosis

Answer 30

causes intermittent claudication, postural color changes, and trophic changes in the skin

Question 31

an exaggerated, widened femoral pulse

Answer 31

femoral aneurysm, a pathologic dilation of the artery

Question 32

an exaggerated, widened popliteal pulse

Answer 32

aneurysm of the popliteal artery

Question 33

Popliteal and femoral aneurysms

Answer 33

not common, but they are usually caused by arteriosclerosis and occur primarily in men older than 50 years

Question 34

Atherosclerosis (arteriosclerosis obliterans)

Answer 34

most commonly obstructs arterial circulation in the thigh. The femoral pulse is normal, the popliteal decreased or absent

Question 35

dorsalis pedis artery

Answer 35

may be congenitally absent or may branch higher in the ankle. search for a pulse more laterally

Question 36

What does the absent pedal pulses with normal femoral and popliteal pulses indicate?

Answer 36

atherosclerotic disease in the lower popliteal artery or its branches 14 times more likely, seen in diabetes mellitus

Question 37

What does sudden arterial occlusion from embolism or thrombosis cause?

Answer 37

causes pain and numbness or tingling. The limb distal to the occlusion becomes cold, pale, and pulseless. Emergency treatment is required

Question 38

What does coldness, especially when unilateral or associated with other signs suggest?

Answer 38

suggests inadequate arterial perfusion

Question 39

What does the edema cause?

Answer 39

causes swelling that may obscure the vein, tendons, and bony prominences

Question 40

What does calf asymmetry increase the likelihood of?

Answer 40

DVT. Also consider muscle tear or trauma, Baker’s cyst (posterior knee) and muscular atrophy

Question 41

In DVT, the location of edema suggests the location of the occlusion:

Answer 41

the popliteal vein when the lower leg or the ankle is swollen; the iliofemoral veins when the entire leg is swollen

Question 42

What does venous distention suggest?

Answer 42

a venous cause of edema

Question 43

When is the bilateral edema present?

Answer 43

in heart failure, cirrhosis, and nephrotic syndrome

Question 44

What does a painful, pale swollen leg, together with tenderness in the groin over the femoral vein, suggest?

Answer 44

deep iliofemoral thrombosis

Question 45

What is the risk of pulmonary embolism in proximal vein thrombosis?

Answer 45

50%. Only half of patients with DVT in the calf half tenderness and cords deep in the calves. Absence of calf tenderness does not rule out thrombosis

Question 46

Superficial thrombophelbitis

Answer 46

local swelling, redness, warmth, and a subcutaneous cord. It is an emerging risk factor for DVT

Question 47

Chronic venous insufficiency

Answer 47

brownish discoloration or ulcers just above the malleolus

Question 48

What does thickened brawny skin suggest?

Answer 48

lymphedema and advanced venous insufficiency

Question 49

Varicose veins

Answer 49

dilated and tortuous. Their walls may feel somewhat thickened.

Question 50

What do both Buerger’s disease or thromboangiitis obliterans have in common?

Answer 50

Absent or diminished pulses at the wrist. Arterial occlusive disease is much less common in the arms than in the legs.

Question 51

Allen test

Answer 51

It is useful to ensure the patency of the ulnar artery before puncturing the radial artery for blood samples.

Question 52

What does extending the hand fully may cause in Allen test?

Answer 52

a falsely positive Allen test

Question 53

What does persisting pallor indicate in Allen test?

Answer 53

occlusion of the ulnar artery or its distal branches

Question 54

What does marked pallor on elevation of both legs suggest?

Answer 54

arterial insufficiency

Question 55

When patient sits up with legs dangling down after having to raise the legs for a minute, if the left foot is still pale and the veins are just starting to fill,

Answer 55

it is a sign of arterial insufficiency

Question 56

When patient sits up with legs dangling down after having to raise the legs for a minute, if there is persisting unusual rubor to replace the pallor of the dependent foot,

Answer 56

it is a sign of arterial insufficiency. When veins are incompetent, dependent rubor and the timing of color return and venous filling are not reliable tests of arterial insufficiency

Question 57

Retrograde filling (Trendelenburg) test

Answer 57

assess the valvular competency in both the communicating veins and saphenous system

Question 58

What does rapid filling of the superficial veins while the saphenous vein is occluded indicate?

Answer 58

incompetent valves in the communicating veins. Blood flows quickly in a retrograde direction from the deep to the saphenous system

Question 59

What does sudden additional filling of superficial veins after release of compression indicate?

Answer 59

incompetent valves in the saphenous vein