43. DPR | History and Physical Exam of the Cardiovascular Part II

Which side of the heart pumps blood to the lungs?

The right heart pumps blood to the lungs (pulmonary circulation).

Which side of the heart pumps blood to the systemic circulation?

The left heart pumps blood to the systemic circulation.

Which arteries are commonly examined in the peripheral vascular exam?

Carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis.

Which veins are commonly examined in the peripheral vascular exam?

Jugular veins (central venous pressure), femoral, great saphenous, popliteal, tibial veins.

What is the functional concept of the peripheral vascular system?

Think pump + plumbing; disease in one vessel bed often signals disease elsewhere.

What are lymph nodes?

Aggregates of lymphoid tissue; act as 'trash cans' of the body.

What is the role of lymphatic capillaries?

They intertwine with arterial and venous capillaries to absorb interstitial fluid.

What lymphatic organs are part of the system?

Lymph nodes, spleen, tonsils, thymus.

What are the major regions of lymphatic drainage?

Head/neck, axilla, upper extremities, abdomen, inguinal/lower extremities.

What size is considered abnormal for a lymph node?

Greater than 1 cm.

What is regional lymphadenopathy?

Localized to a single region such as cervical, inguinal, or axilla.

What is generalized lymphadenopathy?

Enlargement in two or more regions.

What are possible causes of lymphadenopathy?

Infection (reactive), malignancy, autoimmune, idiopathic, benign enlargement.

What history elements should be asked for lymphatic issues?

Onset, duration, changes over time, local causes (bite, wound, infection), systemic symptoms (fever, chills, sweats, weight loss).

What social history factors are important for lymphatic evaluation?

Tobacco, alcohol, IV drug use, travel, pets, animal exposure.

What lymph node finding suggests malignancy?

Hard or fixed lymph nodes.

What lymph node finding suggests infection?

Tender or warm nodes with overlying erythema or fluctuance (possible abscess).

What lymph node finding suggests benign or reactive process?

Soft, mobile nodes.

What does supraclavicular lymphadenopathy suggest?

Chest or abdominal malignancy.

What does infraclavicular lymphadenopathy suggest?

Non-Hodgkin lymphoma.

What does axillary lymphadenopathy suggest?

Drains breast, thoracic wall, upper extremity; possible malignancy spread.

What does epitrochlear lymphadenopathy suggest?

If >5 mm, can indicate distal infection, melanoma, or lymphoma.

What does inguinal lymphadenopathy suggest?

Can be benign/reactive, or due to STI, carcinoma, or lymphoma.

What general observation findings suggest vascular disease?

Wheelchair use, walking aids, oxygen use, scars, amputations.

What does jugular venous pressure (JVP) represent?

It reflects right atrial pressure.

When is JVP increased?

Fluid overload, pulmonary hypertension, right heart failure.

When is JVP decreased?

Hypovolemia (e.g., dehydration, blood loss).

What is a bruit?

A sound of turbulent blood flow heard on auscultation.

What is a thrill?

A palpable vibration over an artery due to turbulence.

What extremity findings indicate poor circulation?

Color changes, missing digits, hair loss, ulcers, scars, gangrene.

What is normal capillary refill time?

What does prolonged capillary refill time suggest?

Peripheral vascular disease or shock.

What are the grades of pulses?

0 = absent, 1+ = diminished, 2+ = normal/brisk, 3+ = bounding.

What is the Allen test?

Compress radial and ulnar arteries, then release; tests collateral flow.

When is the Allen test performed?

Before radial arterial line insertion (not routine).

What abdominal finding suggests an abnormal aorta?

Aortic pulsations >3 cm.

Which arteries should be auscultated in the abdomen?

Aortic, renal, iliac, and femoral arteries.

What are features of a peripheral arterial disease ulcer?

Distal, painful, punched-out, shiny hairless skin, possible gangrene.

What are features of a venous ulcer?

Irregular borders, brown hyperpigmentation, edema, stasis dermatitis.

What are the phases of Raynaud's phenomenon?

Pallor→ cyanosis→ rubor.

What are varicosities?

Dilated, tortuous superficial veins.

What is grade 0 edema?

No pitting edema.

What is grade 1+ edema?

Barely detectable depression, instant rebound.

What is grade 2+ edema?

Slight indentation, rebounds in <15 seconds.

What is grade 3+ edema?

Deeper pit, rebounds in 15–30 seconds.

What is grade 4+ edema?

Very deep pit, rebounds in >30 seconds.

What systemic diseases can cause edema?

Heart failure, renal failure, liver failure, malnutrition.

What medications can cause edema?

Antihypertensives.

What is dependent edema?

Edema from standing or sitting due to increased hydrostatic venous pressure.

What is chronic venous edema?

Leads to brown hyperpigmentation, venous stasis dermatitis, and ulcers.

What are the principles of documenting a PVS exam?

Do not write 'normal'; document both present and absent findings; always specify bilaterally.

Give an example of normal JVP documentation.

JVP not elevated.

Give an example of normal carotid documentation.

Carotids without bruits, 2+ symmetric pulses.

Give an example of normal peripheral pulse documentation.

Radial, dorsalis pedis, and posterior tibial pulses 2+ bilaterally.

Give an example of normal capillary refill documentation.

Capillary refill <2 seconds.

Give an example of normal edema documentation.

No edema in feet, ankles, tibia.

Give an example of normal lymph node documentation.

No cervical, axillary, or inguinal lymphadenopathy.

Give an example of abnormal carotid documentation.

Left carotid bruit, none on right.

Give an example of abnormal radial pulse documentation.

Left radial pulse diminished (1+), right radial 2+.

Give an example of abnormal edema documentation.

2+ ankle edema bilaterally.

Give an example of abnormal lymph node documentation.

Right supraclavicular lymph node palpable, none on left; small mobile anterior cervical lymphadenopathy bilaterally.

What is claudication?

Leg pain or cramping during exertion that is relieved by rest within 10 minutes.

What are clinical signs of peripheral arterial disease?

Claudication, non-healing ulcers, gangrene, hair loss, diminished/absent pulses.

What are risk factors for aortic aneurysm/dissection?

Older age, smoking history.

What are key symptoms of aortic aneurysm/dissection?

Abdominal or flank pain, pulsatile abdominal mass, urinary retention/distention.

What are symptoms of mesenteric ischemia?

Postprandial pain, food fear, weight loss.

What is the classic color sequence in Raynaud's phenomenon?

White→ blue→ red.

What are clinical findings of venous insufficiency?

Dependent edema, brown stasis dermatitis, varicosities, venous ulcers.

What are clinical findings of lymphedema?

Firm, non-pitting edema; history of malignancy, lymph node removal, or parasites.

What is the clinical significance of supraclavicular lymphadenopathy?

Strong association with chest or abdominal malignancy.

What is the clinical significance of infraclavicular lymph nodes?

Associated with non-Hodgkin lymphoma.

A 68-year-old man with a history of smoking presents with severe abdominal and flank pain. On exam, a pulsatile abdominal mass is palpated measuring greater than 3 cm. Which condition is most likely?

A. Mesenteric ischemia
B. Abdominal aortic aneurysm
C. Raynaud’s phenomenon
D. Venous insufficiency
E. Lymphedema

B

• A pulsatile abdominal mass >3 cm in an older smoker is classic for abdominal aortic aneurysm (AAA).

  • A. Mesenteric ischemia: Presents with postprandial abdominal pain and “food fear,” not pulsatile mass.

  • B. Abdominal aortic aneurysm: Pulsatile mass, flank pain, older smoker → correct.

  • C. Raynaud’s phenomenon: Color changes in fingers with cold, not abdominal findings.

  • D. Venous insufficiency: Causes edema, ulcers, stasis dermatitis in legs.

  • E. Lymphedema: Firm, non-pitting edema after malignancy or lymph node removal, no pulsatile mass.

A 45-year-old man presents with an enlarged, hard, fixed supraclavicular lymph node. Which of the following is the most likely concern?

A. Local cervical infection
B. Chest or abdominal malignancy
C. Reactive lymphadenitis
D. Benign hyperplasia
E. Non-Hodgkin lymphoma

B

Supraclavicular lymphadenopathy is highly associated with malignancy of the chest or abdomen.

• A. Local cervical infection: More likely with anterior cervical nodes, tender/mobile.

• B. Chest/abdominal malignancy: Hard, fixed, supraclavicular node = classic.

• C. Reactive lymphadenitis: Mobile, soft, tender, usually due to infection.

• D. Benign hyperplasia: Would not be hard and fixed.

• E. Non-Hodgkin lymphoma: Associated more with infraclavicular nodes.

During a physical exam, a physician notes bilateral pitting edema of the ankles rated as 3+. Which of the following descriptions is correct for this grading?

A. Barely detectable depression, instant rebound
B. Slight indentation, <15 seconds rebound
C. Deeper pit, 15–30 seconds rebound
D. Very deep pit, >30 seconds rebound
E. Non-pitting, firm edema

C

• 1+: Barely detectable, instant rebound.

• 2+: Slight indentation, <15 sec rebound.

• 3+: Deeper pit, 15–30 sec rebound → correct.

• 4+: Very deep, >30 sec rebound.

• E: Lymphedema is firm, non-pitting.

A 55-year-old woman presents with a painful ulcer near the lateral malleolus. The ulcer has irregular borders, surrounding brown hyperpigmentation, and edema. Which of the following is the most likely cause?

A. Venous insufficiency
B. Peripheral arterial disease
C. Diabetic neuropathy
D. Trauma
E. Lymphedema

A

• A. Venous insufficiency ✅ – Venous ulcers: irregular borders, brown stasis dermatitis, edema.

• B. PAD ❌ – Ulcers are distal, punched-out, painful, shiny skin, diminished pulses.

• C. Diabetic neuropathy ❌ – Ulcers on plantar surface, painless due to neuropathy.

• D. Trauma ❌ – Could cause ulcers, but without chronic venous changes.

• E. Lymphedema ❌ – Causes firm, non-pitting swelling, not ulcers.

A 46-year-old man presents with an enlarged, firm, immobile node in the infraclavicular region. Which of the following conditions is most strongly associated with this finding?

A. Chest or abdominal malignancy
B. Non-Hodgkin lymphoma
C. Distal infection of the upper extremity
D. Metastatic prostate cancer
E. Autoimmune thyroiditis

B

• A. Chest/abdomen malignancy ❌ – Linked to supraclavicular, not infraclavicular nodes.

• B. Non-Hodgkin lymphoma ✅ – Infraclavicular nodes are classically associated with NHL.

• C. Distal arm infection ❌ – Would affect epitrochlear nodes.

• D. Prostate cancer ❌ – Spreads to pelvic/inguinal nodes, not infraclavicular.

• E. Thyroiditis ❌ – Involves cervical nodes.

A 40-year-old woman presents with an enlarged lymph node in the medial elbow region. On exam, the epitrochlear node measures 7 mm. Which of the following is the most likely underlying condition?

A. Benign reactive enlargement
B. Distal arm infection, melanoma, or lymphoma
C. Supraclavicular spread of abdominal malignancy
D. Venous insufficiency
E. Congestive heart failure

B

• A. Benign ❌ – Epitrochlear nodes >5 mm are pathologic.

• B. Distal infection/melanoma/lymphoma ✅ – Classic causes of enlarged epitrochlear nodes.

• C. Supraclavicular malignancy ❌ – Not an epitrochlear finding.

• D. Venous insufficiency ❌ – Causes leg edema, stasis dermatitis, not lymphadenopathy.

• E. CHF ❌ – Causes pitting edema, not node enlargement.