Comms: Peripheral Vascular histories

Question 1

What questions should you ask the patient in a suspected cardiovascular disease history?

Answer 1

Heart Palpitations
Chest pain on exertion
SOB on exertion
Ankle swelling
Otrhopnoea (SOB on lying relieved by upright position)
Claudication - muscle pain in lower limbs after exercise relieved by rest due to lack of oxygen
Paroxysnak nocturnal dyspnea - SOB that wakes up the patients

Question 2

What questions should you ask a patient in a suspected peripheral vascular disease?
(arterial or venous disease)

Answer 2

Cramp in leg after exercise, better with rest
Pain in feet/legs at night or rest
Ulcers in feet/legs
COld extremities
Swelling in legs/feet
Pain in legs/feet
Numbness in legs/feet
Impaired movement of extremities
Chest pain
SOB.

Question 3

What is considered as peripheral vascular system?

Answer 3

Blood vessels of the body aside from chest and head
Notes Peripheral Vascular Disease normally affects the legs.

Question 4

What is the naming term for conditions associated with veins?

Answer 4

Phleb/veno

Question 5

What is atherosclerosis?

Answer 5

The build up of fats to form plaques inside arteries.

Question 6

What is extravasation?

Answer 6

When things that would normally be in a blood inside the blood vessels leak into surrounding tissue

Question 7

What is ischemia?

Answer 7

Blood and oxygen flow is insufficient to meet the metabolic demands of the tissues.

Question 8

What is thrombosis in situ?

Answer 8

What a fatty deposits causes a blockage of a blood vessels by a colour from an existing narrowed area of atherosclerosis.

Question 9

What is a thromboembolism?

Answer 9

A blooc clot blocks a vessel that started in a vessel in one place and breaks off to move to another.

Question 10

What is peripheral arterial disease? (PAD)

Answer 10

Significant narrowing of the arteries usually due to atherosclerosis
More common in the legs as higher muscle mass so more O2 demand and more likely to get atherosclerosis
Causes limb ischemia and progresses in stages.

Question 11

Who is more likley to get peripheral arterial disease?

Answer 11

Age over 50yrs, rapid increase in incidence once over 65yrs
Increased risk in smoking, hypertension, dyslipidemia, diabetes

Question 12

How common are symptoms of PAD?

Answer 12

Only in 20-25% of patients.

Question 13

How preventative care might be needed in a patients with PAD?

Answer 13

Atherosclerosis in elgs may indicate atherosclerosis elsewhere, such as bowel, brain and coronary arteries
Should try to reduce risk factors for other cardiovascular conditions such as these alongside treating the leg
This will prevent MI and stroke.

Question 14

What are the stages of progression of peripheral arterial disease?

Answer 14

Asymptomatic
Intermittent claudication
Night/rest pain
Tissue loss.

Question 15

Why might PAD patient by asymptomatic?

Answer 15

Other condition preventing walking/exercise ability - so low metabolic demand that can still be reached by low blood supply never reach the claudication stage.
Examples: asthma and COPD

Aim to - control risk factors, treat condition.

Question 16

What is intermittent claudication, what causes it?
Treatment recommendation

Answer 16

Pain felt in legs on walking (due to ischemia)
Tight and cramp-like, worse uphill or with more exercise
Improves with rest but will restart again
This doesn’t cause damage to the limb but can be a marker for widespread atherosclerotic disease
Affect on patients depends on activity demands - can decrease patient activity as try to avoid pain.
To treat encourage regular exercise (2 hours over the course of the week)

Question 17

Why do PAD get pain at night/rest?
What is the treatment priority?

Answer 17

Further narrowed blood flow
Unable to meet metabolic demands at rest - described as burning
Often wakes patient
Can be worse when lying down as no gravity to help blood supply
Relived by hanging feet down from the bed
Can encourage the patients the sleep sitting in a chair - can cause odema and worsen condition by narrowing blood supply further.

Refer to a vascular surgeon indicated to help revascularise the limb as tissue loss will start to occur.

Question 18

What is tissue loss like in PAD?

Answer 18

Ulceration or necrosis (wounds that don’t heal)
Starts distally and spread proximally
Eventually tissue dies on its own without injury
Can be acute, recurrent or chronic.

Question 19

What is an arterial ulcer?

Answer 19

Located on lower legs and tops of feet/toes
Often painful
A symmetrical shape with well defined borders and punched out appearance
Minimal bleeding when touched or knocked
Cool, place or bluish surrounding skin that appears shiny
loss of leg har
Faint or absent pulses.

Question 20

What is the emergency presentation of peripheral arterial disease?

Answer 20

Acute limb ischemia.

Question 21

What is acute limb ishcemia?

Answer 21

Sudden decrease in blood flow due to peripheral arterial disease
Compromises the viability of the limb
Causes irreversible tissue death and may require limb amputations
Symptoms: pain, pale, pulseless, perihingly cold, parasthetsia, paralysis.

Question 22

How can you differentiate between claudication pain and acute limb ischemia

Answer 22

Claudication - tends to be in the calf, tight or cramping, improves with rest, predictable (particular route ‘uphill’ or distance)
Acute ischemia - tends to be in the foot, pins and needles for paresthesia,

Question 23

What are the three types of pain in PAD?

Answer 23

Claudication
Night pain/rest pain
Acute limb ischemia.

Question 24

What past medical history may be important in PAD?

Answer 24

Any vascular disease - angina, MI, TIA, stroke, aneurysm, vascular dementia, leg ulcers.
Risk factors - age, hypertension, high cholesterol, smoking, diabetes, obesity
Any comorbidities that may mask the seriousness of the PAD - asthma, COPD.

Question 25

How can abdominal pain be vascular in origin? Different types.

Answer 25

Can be mesenteric artery disease, due to high anastomosis patient is less likely to have symptoms. Types include: Mesenteric ischaemia Acute ischemic bowel. Abdominal aortic aneurysm.

Question 26

What is mesenteric ischemia?

Answer 26

pain shortly after eating, as the gut requires more blood flow

Question 27

What is acute ischemic bowel?

Answer 27

usually from embolus from left atrium of heart or thrombus in situ, portion of bowel dies, becomes leaky and bacteria passes into abdominal cavity from gut can cause severe pain and major abdominal tenderness, risk of severe sepsis, must have surgery to remove portion of bowel

Question 28

What is an abdominal aortic aneursym?

Answer 28

Dilation of aorta to 1.5x normal. Asymptomatic norm - usually an incidental finding or screening for men over 65yrs. May be aware of pusling abdomen. 80% mortality if ruptures causes sudden onset abdominal/back pain.

Question 29

What are the consequence of carotid atherosclerosis?

Answer 29

One of the main risk factors for stroke and TIA TIA 9 temporary - less than 30mins up to 24 hours

Question 30

Define stroke

Answer 30

A neurological deficit attributed to an acute focal injury of the CNS by a vascular cause.

Question 31

What is raynauds?

Answer 31

raynauds Phenomenon - spasms or blockage of arteires due to cold or emotion Pallor - blood flow blocked by a known cause, cyanosis as oxygen used up, hyperarema (red) as blockage relieved and sudden influx of oxygenated blood Raynauds syndrome - underlying cause, connective tissue disease or beta blockers Raynauds - artery spasm cause is unknown.

Question 32

How should you differentaite between raynauds and peripheral arterial disease?

Answer 32

R - younger adults/teenagers, bilateral PAD - older, one sided, other significant cardiovascular risk features, risk of angina or stroke.

Question 33

What is a Deep vein thrombosis?

Answer 33

A blood clot in a deep vein - usually lower leg to thigh

Question 34

How does a deep vein thrombosis normally present?

Answer 34

Limb pain and or tenderness mostly in calf (over days) Swelling of the calf or thigh (venous blood does not rejoin circulation Pitting odema Distention of superficial veins Red or warm skin.

Question 35

What is the difference between a provoked or unprovoked DVT?

Answer 35

Provoked - clear reason e.g a major surgery Unprovoked - without clear reasons (may have risk factor e.g obesity and age) Undiagnosed cancer needs to be considered - as increases risk of blood clotting.

Question 36

What is varicose veins?

Answer 36

Distal tortuous dilated superficial vein. Often to inner aspect of calf/thigh Can be multiple and bilateral Caused when vales become incompetent, higher pressure in veins allows the backflow of blood. Risk factor is a previous DVT, leading to chronic high BP in the venous system

Question 36

What are some risk factors for a DVT/PE?

Answer 36

Previous DVT/PE Immobilisation e.g after surgery, in plaster cast Cancer Pregnancy and post-partum Severe dehydration Thrombophilia (genetic disease) Family history of VTE Oral oestrogen/progesterone Smoking Obesity Age >60yrs

Question 37

What are some presentations for varicose veins?

Answer 37

Skin changes - rash, eczema, darker pathces, lighter patches, scars, thickedn, hard or tight skin. Haemosiderin - brown iron containing pigment leaks of of status blood and stains legs brown Varciose eczema - red, scaly, blisters skin often starts above inner ankles Lipodermatosclerosis Ulcerations Superficial thrombophlebitis - a hard, painful, tender inflamed lump at the site of a vein Bleeding Pain - worse after standing or end of day

Question 38

What is lipodermatosclerosis?

Answer 38

Hardening of fat and skin Caused by chronic inflammation in response to leaked substances from the blood Often more noticeable lower done Goves a tight, red/purple appearance to skin - responsible for champagne bottle leg appearance.

Question 39

What are the core presentations of peripheral vascular system histories?

Answer 39

Leg pain - intermittend claudication, acute limb ischemic limb, DVT, varicose veins Leg swelling - DVT< venous insufficiency Ulcers and poorly healing wounds - arterial disease and venous insufficiency Finger colour changes - raynauds or PAD of arm Abdominal pain - mesenteria ischaemia/ ischaemic bowel/ AAA.

Question 40

What is the most important risk factors for peripheral vascular disease?

Answer 40

Smoking.