Peripheral vascular system

Question 1

What is the atherosclerotic disease distal to the aortic bifurcation with pain, swelling, and/or discoloration?

Answer 1

peripheral arterial disease

Question 2

What is the thromboembolic disorder of peripheral venous systems in lower extremities that may present with DVT (2/3) or PE (1/3)?

Answer 2

peripheral venous disease

Question 3

What are you examining in the upper extremities exam?

Answer 3

inspect size, symmetry, skin, color

palpate radial & brachial pulses

palpate axillary and epitrochlear lymph nodes

Question 4

What are you examining in the lower extremities exam?

Answer 4

• size, symmetry, skin color
• palpate femoral pulse
• palpate popliteal, dorsalis pedis, and posterior tibial pulses
• check for peripheral edema, ulcerations

Question 5

How do you grade a normal pulse?

Answer 5

2+ = brisk, expected

Question 6

What are some abnormal pulse gradings?

Answer 6

0 = absent
1+ = diminished, weaker than expected
3+=bounding

Question 7

What are you noting upon your peripheral arm inspection?

Answer 7

• symmetry
• swelling
• venous patterns
• color of skin and nail beds
• texture

Question 8

What does a straight edge line formed by tops of knuckles mean?

Answer 8

Edema preventing full closure of hand

Question 9

What does a shiny top of hand mean, with no tendons visible, nor any wrist wrinkles?

Answer 9

Edema

Question 10

What disease involves spasms of distal arteries causing sharply demarcated pallor? Note: this can vary in color

Answer 10

Raynaud’s disease

Question 11

In Raynaud’s disease can you feel radial and ulnar pulses?

Answer 11

Yes

Question 12

Where can you find the brachial artery?

Answer 12

just medial to biceps tendon at antecubital crease, or can be found higher in the arm in groove between biceps and triceps tendon

Question 13

What nodes are you palpating near the brachial artery and on the distal side as well?

Answer 13

epitrochlear nodes

Question 14

How do you palpate epitrochlear nodes?

Answer 14

flex elbow 90 degrees and support elbow with hand while palpating groove between biceps and triceps approx 3 cm above medial epicondyle

difficult or impossible to identify in healthy people

Question 15

Which hand would you use to examine the patient’s right axillae?

Answer 15

The left. always use the opposite.

Question 16

What are you looking for in the abdomen examination?

Answer 16

AAA – aortic pulsation could be a sign

Question 17

What is the normal range for an aorta?

Answer 17

1.4-3cm

Question 18

Where else should you palpate in the abdomen vasculature?

Answer 18

superficial inguinal nodes
normal = 1-2cm non-tender, discrete

Question 19

What arteries are you auscultating in the abdomen?

Answer 19

aorta, renal arteries, iliac arteries, femoral arteries

Question 20

What are you looking for when inspecting the arteries of the leg?

Answer 20

• size, symmetry, swelling, edema
• venous patterns
• pigmentation
• color and texture
• distribution of hair
• varicosities
• unilateral or bilateral?

Question 21

What do you do if you detect unilateral swelling?

Answer 21

1. measure both calves and compare
2. measure 10cm below tibial tuberosity
   >3cm difference in circumfrence = higher risk for DVT

Question 22

What’s the difference between rubor and cyanosis in skin?

Answer 22

rubor is dusky redness, while cyanosis has a blue tone to it

Question 23

What does a diminished or absent femoral pulse indicate?

Answer 23

partial or complete proximal occlusion 6x more likely, with downstream pulses also diminished!

Question 24

What does an absent pedal pulse with a normal femoral and popliteal pulse mean?

Answer 24

atherosclerotic disease in lower popliteal artery or distal artery 14x more likely

Question 25

What are you looking for in regards to inspecting veins of the leg?

Answer 25

* unilateral vs bilateral abnormalities * edema * color/texture of the skin * ulcerations * weeping, vesicle formation * varicosities * hard areas/cords

Question 26

What are clear signs of an arterial ulcer?

Answer 26

* punched out appearance * smooth wound edges * pain at night and relieved by elevation * lateral foot * lower extremities = cool to touch * pale, shiny, thin skin * minimal hair growth * minimal drainage

Question 27

What are the characteristics of a venous ulcer?

Answer 27

* shallow and superficial * irregular shape * painful from edema, phlebitis, infection * usually in lower legs or ankles

Question 28

What are risk factors for arterial ulcers?

Answer 28

* vascular insufficiency * uncontrolled BS in DM * limited joint mobility * improper footwear

Question 29

What are risk factors for venous ulcers?

Answer 29

* varicose veins * deep vein thrombosis * incompetent valves * muscle weakness in legs * immobility * pregnancy

Question 30

What is caused by insufficient blood supply to area, causing ischemia?

Answer 30

arterial ulcer

Question 31

What is caused by pooling of blood causing increased pressure in veins?

Answer 31

venous ulcer

Question 32

If swelling is present, where are the three places you should check for edema?

Answer 32

1. dorsum of each foot 2. behind each medial malleolus 3. over the shins

Question 33

What are the different stages of pitting edema?

Answer 33

1. immediate rebound 2. few seconds to rebound 3. 10-12 seconds rebound 4. >20s

Question 34

When should you consider DVT?

Answer 34

complaint of mild pain with walking and rest

Question 35

If the clot from a DVT is in a proximal vein, what is the risk?

Answer 35

PE (50%)

Question 36

What is the Homan's sign?

Answer 36

calf pain on dorsiflexion of the foot checking for DVT, but not very accurate - can make false positive in >50%, and less than 33% in actual DVT

Question 37

What is the Allen test?

Answer 37

comparing the patency of the ulnar and radial arteries

Question 38

What does it mean when there's persisting pallor with the allen test?

Answer 38

occlusion of the ulnar artery

Question 39

What is the Ankle-Brachial index?

Answer 39

ratio of BP measurements in foot and arm -- detecting decreased BP distal to an arterial stenosis, often used to assess PAD

Question 40

How do you measure brachial pressure?

Answer 40

Using a doppler, locating the brachial pulse and utilizing the BP cuff to record pressure at which the pulse becomes audible x2 on each side and average

Question 41

What is an ABI?

Answer 41

right ABI = highest pressure in right foot / highest pressure in both arms

Question 42

What's a normal ABI?

Answer 42

.9-1.4

Question 43

What does an ABI >1.40 indicate?

Answer 43

noncompressible calcified vessel

Question 44

What does an ABI <.9 indicate?

Answer 44

PAD; <.5 = severe PAD

Question 45

What is the Buerger test?

Answer 45

test if pain or diminished pulses = arterial insufficiency raise both legs to 60 degrees for 1 min until max pallor - compare feet/soles of feet, then ask patient to sit up, dangling feet down, compare both feet, timing for return of pinkness <10s, filling of veins <15s

Question 46

What means the Buerger test is abnormal?

Answer 46

* asymmetrical color changes * delayed arterial and venous filling * >30s and/or unusual rubor to replace pallor