Clinical Skills - Exam 5 (PV System)

why is detection of PAD important

bc PAD is a marker for cardiovascular morbidity and mortality

3x risk of MI and stroke

tunica intima

1. makes thrombosis regulators like plasminogen

2. makes prothrombotic factors like VWf

3. makes vasoconstrictors and vasodilators

4. regulates immune and inflammatory rxn

tunica media

smooth muscle

tunica adventitia

CT w/ nerve fibers

valve type in veins

one-way

what veins carry 90% of returning blood in legs

deep femoral veins

superficial leg veins

subq w/ poor support

saphenous and communicating veins

intermittent claudication

pain in legs w/ exertion that lessens with rest in 1-3 min

plaques obstruct bf = low O2

PAD warning signs

-fatigue, aching, numbness that limits walking

-ED

-poorly healing LE wounds

-pain at rest changes w/ standing or supine

-abdominal pain after meals, weight loss = intestinal ischemia

-first degree relative w/ AAA history

horizontal inguinal lymph nodes

drain superficial lower abdomen, buttocks, external genetalia, anal canal, perineum, low vagina

vertical inguinal lymph nodes

drains dorsum of foot, medial leg

not normally palpable

3+ pulse

bounding (aneurysmal)

2+ pulse

brisk, normal

1+ pulse

diminished, weaker than expected

0 pulse

absent, unable to palpate

phlebitis

inflammation of a vein

-venous tenderness

-cords

-heat/erythema

4+ pitting

indentation takes >30 seconds to rebound

3+ pitting

indentation takes 30 sec to rebound

2+ pitting

slight indentation takes 15 sec to rebound

1+ pitting

barely detectable indentation

causes of edema

venous insufficiency

lymphedema

CHF

Nephrotic syndrome

Cirrhosis

Malnutrition

Drugs

Prolonged sitting or standing, ill-fitted shoes

pathology of edema

increased interstitial fluid

2 special tests for PV

allen test

ankle-brachial index

allen test

evaluates arterial supply to hand

ensures patency of ulnar artery before puncturing radial for blood samples

purpose of ankle brachial index

Confirm dx of PAD

-compares BP in UE vs. LE

Homan's sign

previously used for DVT

-can dislodge a clot

-pain = DVT

Untreated PAD can lead to

Peripheral artery occlusion

-ischemia even worse with rest

peripheral artery occlusion

worse at night and with foot elevation

improved w/ dependency

may have numbness or tingling

varicose veins

superficial, dilated, tortuous veins

from incompetent valves

causes of varicose veins

familial

long periods increased venous pressure

secondary to thrombophlebitis

sx of varicose veins

none OR

fatigue, ache, heaviness

signs of varicose veins

dilated veins, may have tissue changes

superficial thrombophlebitis

usually saphenous

-clot in superficial v.

sx of superficial thrombophlebitis

sudden inflammation and dull pain

signs of superficial thrombophlebitis

local redness

pain

edema

palpable cord

causes of superficial thrombophlebitis

pooled blood (pregnancy, post partum, varicose veins)

secondary to trauma like IV or contusion

what is secondary to superficial thrombophlebitis - RARE

pulmonary embolism

usually, condition is benign

2/3 of thromboembolic disorders of PV system are

DVTs

1/3 of thromboembolic disorders of PV system are

PEs

DVT

clot in deep vein of calf

causes of DVT

CHF

hip surgery

neoplasm

pelvic fracture

OCs

smoking

varicose veins with prolonged inactivity

DVT signs and sx

sx - painless at first

signs - edema, possible calf tenderness

prognosis of DVT

can lead to chronic venous insufficiency if valves are destroyed

pulmonary embolism

incompetent valves of varicose veins

-chronic venous occlusion from deep vein thrombophlebitis

-obstruction from trauma or edema of surrounding tissue

chronic venous insufficiency is usually in

women 60+

obesity

h/o leg injury or prolonged standing

sx of chronic venous insufficiency

painless or diffuse leg ache

worse w/ dependency

alleviated with elevation

difference between chronic venous insufficiency and arterial disease

chronic venous insufficiency is relieved by elevation and painless ulcers

arterial disease is aggravated by elevation and ulcers are painful

signs of chronic venous insufficiency

chronic edema @ ankle

stasis dermatitis

brown, brawny pigment

possible painless ulcers

normal pulse

thickened skin

normal temp

no gangrene

causes of lymphedema

lymphatic obstruction

congenital

inflammatory

mechanical

mechanical causes of lymphedema

tumor

trauma

fibrosis

metastatic node disease

post-op for lymph node dissection

signs and sx of lymphedema

soft at first

becomes hard and non-pitting

skin thickening

no ulcers or pigment change

painless

acute lymphangitis

acute bacterial infection from staph or strep

-entry at chronic ulcer or acute injury

-infection spreads up lymph channels

symptoms of acute lymphangitis

throbbing pain

tenderness

fever, chills, malaise

red streaks on skin along lymphatic channel

tender, enlarged lymph nodes

thromboangiitis obliterans (Buerger's disease)

occlusion of small arteries and veins of fingers and toes due to inflammation or thrombus

SMOKERS, men under 4-, asian

symptoms of thromboangiitis obliterans (Buerger's disease)

intermittent claudication in arch of foot and hands, increases with exercise and decreases with rest

pain at rest can be chronic

signs of thromboangiitis obliterans (Buerger's disease)

distal coldness, numbness, cyanosis, ulceration, gangrene

if pt does not quit smoking, can lead to amputation

Raynaud's disease

episodic spasm of small arteries

-SLE, CT disease, vascular disease, blood dyscrasia, occupational exposure

sx of raynauds

1+ distal fingers

b/l

painless/mild pain

numbness or tingling lasting and few minutes

triggers of raynauds

cold

emotional upset

color change in raynauds

white - blue - red

raynauds phenomenon

not the disease, is secondary to conditions like RA, sclerosis, SLE, CT disease

causes of pressure ulcers

bed/wheelchair confined pt

emaciated

elderly

neuro-compromised

diabetic

sites of pressure ulcers

sacral area

buttocks

greater trochanter

knees

heels

occiput

ears

elbows

chronic arterial insufficiency main characteristics

-intermittent claudication progresses to pain at rest

-tissue ischemia

-pulses dec or absent

-skin pain

-skin is cool to touch

-edema mild/absent

-atrophy of skin

-ulcers on toes or trauma

-infection and gangrene can occur

venous arterial insufficiency main characteristics

-painful

-venous HTN

-normal pulse, hard to palpate w/ edema

-cyanotic on dependency, petechiae

-skin normal temp

-marked edema

-brown skin, stasis dermatitis, thickening

-ulcers of medial ankle

renal artery disease is screened for using

screening doppler

renal artery disease risk factors

-Early age of HTN

AAA risk factors

smoker

>65

family hx

CAD

PAD

HTN

dyslipidemia

screening for AAA

one time via ultrasound between 65-75