PD E3: peripheral vascular

what are the 2 most important types of arterial diseases?

microvascular (atherosclerosis) and microvascular (DM)

what are the 2 most important types of venous diseases?

venous stasis and thrombotic disorders

when would you assess the peripheral vasculature?

• pain

• changes in skin temp or color

• edema

• ulceration

• suspect stroke/PE

• cardiac/DM pts

what are risk factors for peripheral vascular dz?

• ≤ 50 w/ DM + one other atherosclerosis risk factor (smoking, dyslipidemia, HTN)

• 50-69 and hx of smoking or DM

• ≥70

• leg sx w/ exertion → ischemic rest pain or intermittent claudication/PAD

• abnormal LE pulse

• atherosclerotic dz of coronary, carotid, or renal arteries

where should BP be measured?

BOTH arms

what should you do if hand perfusion is in question?

allen’s test

what might white discoloration of UE suggest?

raynauds

what might red discoloration of UE suggest?

cellulitis

what might red streaking of UE suggest?

lymphangitis

what might blue discoloration of UE suggest?

cyanosis

How do you rate pulse amplitude?

• 0 → absent, unable to palpate

• 1+ → diminished, weaker than expected

• 2+ → normal, brisk, expected

• 3+ → bounding

what conditions might small/weak pulses be seen in?

• aortic stenosis

• hypovolemia

• dilated CMP

what conditions might large/bounding pulses be seen in?

• aortic regurgitation

• hyperthyroidism

• fever

• anemia

what conditions might bisferiens pulse be seen in?

• aortic regurgitation

• HOCM

what is normal pulse pressure?

30-40 mmHg

what is pulses alternans?

beat to beat variation but regular rhythm

ex: LHF, ventricular decompensation

what is pulses bigeminus?

irregular rhythm w/ alternating strong and weak beats; often caused by premature ventricular contraction

ex: HCM

what is the main difference between pulses alternans and pulses bigeminus?

alternans → regular rhythm

bigeminus → irregular rhythm

what is a paradoxical pulse?

>10 mm dec in SBP during inspiration

ex: pericardial tamponade, constrictive pericarditis, obstructive airway dz

pulse wave contours

too lazy to type lol

what is the Allen test?

tests patency of ulnar artery prior to puncturing the radial artery

1. pt clench fist for 30 s

2. compress both radial and ulnar arteries

3. pt open fist

4. release one artery

5. watch for filling of hand to assess potency of ulnar artery

6. if patent → palm flushes in 3-5s

7. eval patency to prevent ischemia to hand

where are the epitrochlear nodes?

3 cm above medial epicondyle; bt biceps and triceps muscle

where is it common to find lymph nodes in children and adolescents?

around neck and bony prominences

what suggests chronic arterial insufficiency?

• pallor of foot when raised to 60 degrees for 1 min

• pain when walking; usually assoc w/ intermittent claudication

• pale or dusky red color (rubor)

• cool temp

• no edema

• thin/shiny skin

• loss of hair

• painful ulcerations (trauma)

• dry gangrene

• dec pulses

what are the 6 P’s of circulation of arterial insufficiency?

• pain

• pallor

• paresthesia

• paralysis

• pulselessness

• poikilothermia

what is buerger’s test?

used to test for arterial deficiency of LE

1. pt lie flat

2. raise both legs to 45 degrees and hold them up 1 min

3. pt sit up and hang legs off bed

4. observe legs and feet

5. toes remain pink → negative for PAD

6. toes pass through pink to red range color due to reactive hyperemia from post hypoxic vasodilation (sunset foot) → positive for PAD

what is ankle-brachial pressure index (ABPI)?

non invasive quick method of evaluating for suspected arterial insufficiency

1. use handheld doppler and sphygmomanometer

2. measure brachial SBP

3. measure ankle SBP at most distal pulse (DP/PT, then average)

4. ratio of 2 BPs is the ABPI → ankle BP / brachial BP

what are the ranges of ABPI?

• normal: 1-1.4

• mild PAD: 0.8-1.0

• moderate PAD: 0.5-0.8

• severe PAD: ≤ 0.5

What will the ABPI appear in a pt w/ calcified arteries?

falsely elevated

what suggests chronic venous insufficiency?

• brownish pigment

• pitting edema

• skin thickening

• malleolar ulcers

• normal pulses

• no pain

what is BBEDDS?

used for evaluating ulcers

• Basics site, size, shape

• Base

• Edge

• Depth

• Discharge

• Surroundings

what do rolled edges suggest?

BCC

what do everted edges suggest?

SCC

what do flat, sloping edges suggest?

venous

what do punched out edges w/o pain suggest?

neuropathic

what do punched out edges w/ pain suggest?

arterial

what do undermined edges suggest?

pressure sores

neuropathic vs neuroischemic ulcers

still too lazy to type srry

DDX of foot/leg ulcers

he just said to remember the charts in class but still don’t feel like typing

what are varicosities?

dilated, tortuous, thin walled superficial veins

commonly in legs, but also abdominal wall, anus, vulva, esophagus

What are primary varicose veins associated with?

superficial venous insufficiency

what are secondary varicose veins associated with?

deep venous insufficiency

Primary varicose veins

• congenital abnormality

• age related

• occupation

• pregnancy

secondary varicose veins

• anything that raises intra-abdominal pressure or raises pressure in deep venous system

• trauma

• thrombosis

where are you inspecting on the medial side of lower extremities?

along the distribution of the long saphenous vein

where are you inspecting below the knee, posterior and lateral aspects of the legs?

along the distribution of the short saphenous vein

How do you map varicosities?

• place fingers on superior aspect

• sharply compress vein beneath

• feel for pressure wave

what is the trendelenburg test?

evaluate for valvular competency

1. elevate one leg 90 degrees, occlude w/ manual pressure the great saphenous vein and ask pt to stand

2. keep one vein occluded and watch for filling distally

3. >35 s indicates incompetent valves

what is the cough test?

• pt standing

• place fingers over SFJ

• ask pt to cough

• if thrill felt → incompetence

what is the tap test?

• pt standing

• place one hand over SFJ, other on varicosities

• tap SFJ

• if thrill felt → back flow bt SFJ and varicosities → incompetence

what is the perthes test?

• ask pt to stand

• tourniquets around mid thigh

• if veins empty → deep system fine

• if veins swell and become painful → deep vessel occlusion

what is the gold standard for evaluating varicosities/incompetency of SFJ/SPJ?

doppler test

what is the doppler test?

• find SFJ

• place doppler

• squeeze either the thigh or calf

• 1 whoosh as blood goes up → good!

• 2nd whoosh → BAD

  • SFJ incompetent

  • the quicker the 2nd whoosh → the more incompetent the valve

• repeat for SPJ in popliteal fossa

How do you find the sapheno-femoral junction (SFJ)?

• ask pt to lie down

• find femoral pulse (midway bt ASIS and pubic tubercle)

• 2cm medial and 2 cm inferior to femoral pulse

• palpate for sapheno varix- localized dissension of long saphenous vein in groin

How do you evaluate for temperature of extremities?

with the dorsum of your hand;

lift and place don’t rub → “professionalism 0”

what are possible reasons you may not be able to feel a pulse during a physical exam?

• occlusion → atherosclerosis, DM

• stenosis

• congenital anomaly

• edema

Where should you check for pitting edema?

• dorsum of each foot

• behind medial malleolus

• over the shins

How do you grade the depth of pitting edema?

• 1+ → 2 mm

• 2+ → 4 mm

• 3+ → 6 mm

• 4+ → 8 mm

what would cause bilateral symmetrical pitting edema?

CHF

what would cause unilateral soft pitting edema?

DVT

what would cause firm pitting edema w/ hyperpigmentation and thickening of the skin?

chronic venous stasis

what would cause hard, non-pitting edema?

pretibial myxedema

what would cause unilateral, soft to firm tender edema w/ red warm skin?

cellulitis

how does lymphedema appear in early stages?

soft

how does lymphedema appear in later stages?

indurated, hard non pitting edema w/ peu-de-orange skin (dimples like oranges)

what is Homan’s sign?

• checks for DVT

• calf pain elicited upon active passive dorsiflexion of foot

• low sensitivity (rely on physical exam, labs, and diagnostic studies instead)

what should you get when you suspect a DVT?

doppler and u/s

what blood tests would you order for suspected anemia?

CBC w/ ferritin

what blood tests would you order for suspected renal failure or DM?

UA and BMP

what blood tests would you order for suspected atherosclerosis?

fasting lipid panel

what blood tests would you order for suspected CHF?

BNP

What does a murmur-like sound of vascular rather than cardiac origin (bruit) indicate?

partial arterial occlusion

What do you auscultate the carotid arteries with?

bell

How to auscultate the carotids?

• one at a time w/ the bell of stethoscope

• upright and supine position

• listen to at least 3 locations → base of neck, carotid bifurcation, angle of jaw

• listen over subclavian artery to determine if transmitted or originates in carotid

• ask pt to hold breath while listening for bruits

• normal: pulse heard W/O sounds during systole

what does a carotid bruit suggest?

carotid artery stenosis

what does a transmitted murmur heard in the carotids suggest?

aortic stenosis; subclavian artery stenosis

what is a venous hum?

continuous thrill and murmur at root of neck in sitting position that disappears in supine position and w/ compression

*benign and common in children

what does a hyperkinetic carotid pulse suggest?

increased LV SV

what does a hypokinetic carotid pulse suggest?

decreased LV SV

what might a bisferiens carotid pulse suggest?

• aortic stenosis + aortic insufficiency

• aortic insufficiency alone

• HOCM

what might a parvus et tardus carotid pulse suggest?

• (slow rising, low amplitude)

• severe valvular aortic stenosis

where is the contour of the pulse best palpated and defined?

central sites → carotid, brachial, and femoral arteries

Double pulses include…

pulsus biferiens, bifid pulse, pulsus alternans

What is a double pulse of aortic insufficiency?

pulsus biferiens

what kind of pulses would you expect in pericardial tamponade, constrictive pericarditis, and obstructive airway dz?

paradoxical pulses