A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?
A) Intermittent claudication
B) Chest pressure with exertion
C) Shortness of breath
D) Knee pain
Feedback: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of patients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle brachial index can help detect this problem.
A 72-year-old teacher comes to your clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes is a risk factor for peripheral vascular disease? A) Gastroesophageal reflux disease B) Coronary artery disease C) Migraine headaches D) Osteoarthritis
Feedback: Evidence of coronary artery disease implies that there is most likely disease in other vessels; therefore, this is a risk factor for peripheral vascular disease. Conversely, the presence of peripheral vascular disease is also a risk factor for coronary artery disease, and if present, it should be considered in reduction of cardiac risk factors.
A 68-year-old retired truck driver comes to your office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. You are concerned about his risk for peripheral vascular disease. Which of the following tests are appropriate to order to initially evaluate for this condition? A) Venogram B) CT scan of the lower legs C) Ankle–brachial index (ABI) D) PET scan
Feedback: The ankle–brachial index is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Sixteen percent of patients with known peripheral vascular disease also have coronary artery disease.
A 55-year-old secretary with a recent history of breast cancer, for which she underwent surgery and radiation therapy, and a history of hypertension comes to your office for a routine checkup. Which of the following aspects of the physical are important to note when assessing the patient for peripheral vascular disease in the arms?
A) Femoral pulse, popliteal pulse
B) Dorsalis pedis pulse, posterior tibial pulse
C) Carotid pulse
D) Radial pulse, brachial pulse
Feedback: This is an important aspect of physical examination to assess for peripheral vascular disease. This patient is at risk for disease in this distribution because of her recent radiation therapy.
You are a student in the vascular surgery clinic. You are asked to perform a physical examination on a patient with known peripheral vascular disease in the legs. Which of the following aspects is important to note when you perform your examination?
A) Size, symmetry, and skin color
B) Muscle bulk and tone
C) Nodules in joints
D) Lower extremity strength
Feedback: This is an important aspect to note in physical examination. Swelling in the legs, cyanosis, and lack of appropriate hair growth are all signs of peripheral vascular disease.
You are assessing a patient for peripheral vascular disease in the arms, secondary to a complaint of increased weakness and a history of coronary artery disease and diabetes. You assess the brachial and radial pulses and note that they are bounding. What does that translate to on a scale of 0 to 3?
Feedback: A pulse of 3+ is considered to be bounding.
You are obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. You are concerned about the possibility of arterial insufficiency. You perform the Allen test. This means that you:
A) Checked for patency of the radial artery
B) Checked for patency of the brachial artery
C) Checked for patency of the ulnar artery
D) Checked for patency of the femoral artery
Feedback: The Allen test is for determining patency of the ulnar artery before puncturing the radial artery. In the event of an occlusion in the radial artery system, the ulnar artery can provide adequate blood flow.
You are assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the patient’s pain make you concerned for this disease process?
Feedback: Pain in the calf is the most common site for claudication; however, there could be pain in the buttock, hip, thigh, or foot, depending on the level of the obstruction. The absence of this pain does not rule out significant vascular disease, and actually the minority of these patients are symptomatic.
You are performing a routine check-up on an 81-year-old retired cotton farmer in the vascular surgery clinic. You note that he has a history of chronic arterial insufficiency. Which of the following physical examination findings in the lower extremities would be expected with this disease?
A) Normal pulsation
B) Normal temperature
C) Marked edema
D) Thin, shiny, atrophic skin
Feedback: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.
A 77-year-old retired nurse has an ulcer on a lower extremity that you are asked to evaluate when you do your weekly rounds at a local long-term care facility. All of the following are responsible for causing ulcers in the lower extremities except for which condition?
A) Arterial insufficiency
B) Venous insufficiency
C) Diminished sensation in pressure points
Feedback: Hypertension is not directly associated with the formation of ulcers. It is an indirect risk factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to arterial insufficiency or neuropathy
As the internal diameter of a blood vessel changes, the resistance changes as well. Which of the following descriptions depicts this relationship?
A) Resistance varies linearly with the diameter.
B) Resistance varies proportionally to the second power of the diameter.
C) Resistance varies proportionally to the third power of the diameter.
D) Resistance varies proportionally to the fourth power of the diameter.
Feedback: The body is able to make significant changes in blood vessel resistance with very small changes to diameter. LaPlace’s law tells us that the resistance varies proportionally to the fourth power of the diameter.
Which area of the arm drains to the epitrochlear nodes?
A) Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger
B) Radial surface of the forearm and hand, thumb and index fingers, and radial middle finger
C) Ulnar surface of the forearm and hand; second, third, and fourth fingers
D) Radial surface of the forearm and hand; second, third, and fourth fingers
Feedback: The epitrochlear node receives lymphatic drainage from the ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger. More importantly, it is generally a sign of generalized lymphadenopathy as seen in syphilis and HIV infection.
Mr. Edwards complains of cramps and difficulties with walking. The cramps occur in his calves consistently after walking about 100 yards. After a period of rest, he can start to walk again, but after 100 yards these same symptoms recur. Which of the following would suggest spinal stenosis as a cause of this pain?
A) Coldness and pallor of the legs
B) Relief of the pain with bending at the waist
C) Color changes of the skin
D) Swelling with tenderness of the skin
Feedback: While these symptoms are classic for claudication, they may also be accounted for by spinal stenosis. Relief with bending at the waist would be consistent with this etiology. Some will state that they must lean over the shopping cart while shopping to avoid these symptoms. Bending stretches the spinal cord and presumably decreases compression. The other symptoms would lead one to suspect a vascular etiology.
Which of the following pairs of ischemic symptoms versus vascular supply is correct?
A) Lower calf/superficial femoral
B) Erectile dysfunction/iliac or pudendal
C) Buttock/common femoral
D) Upper calf/tibial or peroneal
Feedback: The ischemia from the iliac or pudendal arteries results in erectile dysfunction. The lower calf is supplied by the popliteal artery, the buttock is supplied by the common femoral artery, and the upper calf is supplied by the superficial femoral artery.
The ankle–brachial index (ABI) is calculated by dividing the systolic BP at the dorsalis pedis by the systolic BP at the brachial artery. Which of the following values would be consistent with mild peripheral arterial disease?
Feedback: The mild disease is represented by an ABI of 0.71 to 0.9. Any value above 0.9 is normal. Moderate disease is defined as between 0.7 and 0.41, and severe disease is defined as 0.4 or less. Patients in the “severe” category have a 20% to 25% annual risk of death.
Asymmetric BPs are seen in which of the following conditions?
A) Coronary artery disease
B) Congenital narrowing of the aorta
C) Diffuse atherosclerosis
D) Vasculitis, as seen in systemic lupus erythematosus
Feedback: A difference of as little as 10 mm Hg in the systolic blood pressure may be significant. Coarctation and dissecting aortic aneurysm are causes of asymmetric blood pressures. Coarctation represents a congenital narrowing of the aorta. While some forms of vasculitis can affect large vessels where we measure the blood pressure, lupus is generally a small-vessel vasculitis. Usually, neither diffuse atherosclerosis nor coronary artery disease is responsible for a focal difference in blood pressure.
Diminished radial pulses may be seen in patients with which of the following?
A) Aortic insufficiency
C) Arterial emboli
D) Early “warm” septic shock
Feedback: Arterial emboli would decrease flow to a region, and therefore pulses would decrease as well. The other conditions actually cause bounding pulses. Aortic insufficiency can cause significant leakage of blood back to the heart, so the heart compensates by increasing forward flow. Stroke volume can increase dramatically with hyperthyroidism, especially in “thyroid storm.” This also results in bounding pulses. Although shock generally causes decreased blood pressure and pulses, early septic shock can produce increased peripheral circulation and increase pulses.
When assessing temperature of the skin, which portion of your hand should be used?
C) Backs of fingers
D) Ulnar aspect of the hand
Feedback: The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. You may have difficulty detecting subtle differences if you do not use the backs of the fingers.
A patient presents with claudication symptoms and diminished pulses. Which of the following is consistent with chronic arterial insufficiency?
A) Pallor of the foot when raised to 60 degrees for one minute
B) Return of color to the skin within 5 seconds of allowing legs to dangle
C) Filling of the veins of the ankles within 10 seconds of allowing the legs to dangle
D) Hyperpigmentation of the skin
Feedback: Pallor of the soles after one minute of elevation is a reliable sign of arterial insufficiency. Return of the color to the skin should occur within 10 seconds of dangling, and the filling of veins should occur within 15 seconds. Hyperpigmentation of the skin is usually seen in venous insufficiency.
You note a painful ulcerative lesion near the medial malleolus, with accompanying hyperpigmentation. Which of the following etiologies is most likely?
A) Arterial insufficiency
B) Neuropathic ulcer
C) Venous insufficiency
Feedback: These features are most consistent with venous insufficiency. You may also see scaling, redness, varicosities, and other findings. Arterial insufficiency usually affects distal or traumatized areas. Other clues of arterial insufficiency would most likely be present. Neuropathic ulcers occur because of decreased sensation and are common in patients with neuropathy. They are often over bony prominences with surrounding calluses.