Physiologic Exams Flashcards
(126 cards)
1
Q
A patient presents with HTN, DM and left lower extremity pain that occurs only as he walks. He usually begins to have pain after he walks to his mailbox with increasing pain as he returns to the house. The pain is relieved by resting his legs for a few minutes. What would the predicted ABI value be for the left leg?
A. 0.9
B. 0.6
C. 0.4
D. above 1.0; these symptoms are most likely unrelated to arterial disease
A
B
The patient is experiencing claudication which is found in patients with 0.5 - 0.9 ABI. The short distance of walking to the mailbox before the pain begins indicates a more significant amount of disease than 0.9 ABI would indicate. An ABI of 0.6 is the best choice with the given symptoms.
2
Q
Which of the following is a characteristic of a normal arterial PPG waveform? A. low amplitude B. slow downslope C. prominent dicrotic notch D. slow upslope
A
C
An abnormal PPG waveform will demonstrate a loss of the dicrotic notch, slow upslope, slow downslope and little difference between systolic and diastolic blood volumes.
3
Q
A patient presents with left lower extremity pain that awakens him at night. The pain is relieved by sitting at the side of the bed for a few minutes. What would the predicted ABI value be for the left leg?
A. 0.8
B. 0.6
C. 0.4
D. above 1.0; these symptoms are most likely unrelated to arterial disease
A
C
The patient is experiencing rest pain which is found in patients with an ABI less than 0.5.
4
Q
If the blood pressure in the ankle is obtained with the patient’s legs in the dependent position:
A. the pressure will be underestimated
B. the ankle will demonstrate the same response as if an exercise exam was just performed
C. the pressure will be falsely elevated
D. it will be the same as if the patient is evaluated in the supine position
A
C
If the blood pressure in the ankle is obtained with the patient’s legs in the dependent position, the pressure will be falsely elevated due to the effects of hydrostatic pressure.
5
Q
Lower extremity arterial segmental pressure exam results in a post exercise basal pressure recovery time of 2 to 6 minutes which suggests: A. multi-level stenosis B. iliac disease C. single level stenosis D. thoracic outlet syndrome
A
C
Lower extremity arterial segmental pressure exam resulting in a post exercise basal pressure recovery time of 2 to 6 minutes suggests single level disease. Lower extremity arterial doppler exam resulting in a post exercise basal pressure recovery time greater than 6 minutes suggests multi-level disease.
6
Q
When performing post-occlusive reactive hyperemia, pressure measurements in the lower extremities are obtained:
A. immediately after cuff release and every 2 minutes until pressures return to baseline levels
B. 1 minute after cuff release and every 2 minutes until pressures return to baseline levels
C. 1 minute after cuff release and every 30 seconds until pressures return to baseline levels
D. immediately after cuff release and every 30 seconds until pressures return to baseline levels
A
D
When performing post-occlusive reactive hyperemia of the lower extremities, pressure measurements are obtained immediately after cuff release and every 30 seconds until pressures return to baseline levels. Recovery time is shorter for reactive hyperemia than treadmill testing.
7
Q
A 65yr old male presents with mild left calf pain after walking 10 blocks. The pain is relieved by sitting and resting. On a resting arterial exam with ABI, the left ABI is 1.04. These findings are most suggestive of:
A. the venous system should be evaluated for possible insufficiency
B. an exercise arterial should be performed to re-evaluate the ABI of the left leg before a diagnosis is made
C. the venous system should be evaluated for thrombosis
D. the patient is most likely experiencing an orthopedic or neurogenic problem and an MRI may be warranted
A
B
Because the symptoms occur when the patient is walking, the leg should be elevated with exercise to completely rule out a vascular diagnosis.
8
Q
Pulse volume recording:
A. will demonstrate waveforms that are nearly identical to the analog Doppler waveforms in a normal patient
B. readings should be taken beginning with the distal cuff and moving proximally
C. is used to assess arterial insufficiency and DVT
D. is commonly performed with a segmental pressure exam
A
D
Pulse volume recording is used to assess arterial and venous insufficiency, not DVT. PVR exams are usually performed with segmental pressure exams. Readings are taken first in the proximal extremity and then moving distally to the next cuff. The normal waveform will be monophasic with rapid upstroke, sharp systolic peak, prolonged downstroke and prominent reflection (dicrotic notch). Normal Doppler tracings would be triphasic.
9
Q
When performing a photoplethysmography exam for venous insufficiency, where should you place the sensor? A. distal pad of the great toe B. dorsal aspect of the great toe C. medial distal calf D. groin
A
C
Venous insufficiency is assessed by placing the sensor on the distal calf. Arterial disease is assessed by placing the sensor on the pads of the toes.
10
Q
Which of the following patients would benefit from an exercise segmental pressure exam?
A. patient with claudication and resting ABI 0.6
B. patient with COPD and resting ABI of 0.9
C. patient with claudication and a resting ABI of 0.95
D. patient with rest pain and resting ABI 0.4
A
C
A normal resting ABI can become abnormal with exercise in patients with less severe disease. The patient with COPD would most likely be recommended for reactive hyperemia. An ABI that is less than 0.9 demonstrates PAD is present. The exercise exam will not provide any additional information to assist on the diagnosis of these patients.
11
Q
Upon cessation of exercise, the ankle pressures in a normal patient will:
A. increase to normal levels in less than 5 minutes
B. increase to normal levels in less than 10 minutes
C. decrease to normal levels in less than 10 minutes
D. decrease to normal levels in less than 5 minutes
A
D
Upon cessation of exercise, the ankle pressures to normal levels within 5 minutes. Ankle and arm pressures should show a mild increase with exercise. Because they increase at relatively the same levels, the ABI usually stay the same or increases slightly.
12
Q
A patient presents with HTN, DM and left lower extremity pain that worsens as he walks. He usually begins to have pain after he walks to his mailbox with increasing pain as he returns to the house. The pain is relieved by resting his leg for a few minutes. A bilateral resting ABI is performed with the right leg, 1.12 and the left leg 1.34. Which of the following statements is true regarding the findings?
A. medial calcification of the left calf vessels is most likely present
B. these symptoms are most likely unrelated to arterial disease
C. the patient should be evaluated for popliteal entrapment in the left leg
D. hypertension disease usually leads to overestimation of the ABI values
A
A
Patients with diabetes have increased incidence of medial calcification of the extremity vessels which causes falsely increased ABI measurements. An ABI over 1.30 usually indicates the presence of medial calcification.
13
Q
Which of the following will increase the amplitude of a digital PPG tracing?
A. warming the patients foot and toes
B. adding more gel between the skin and the sensor
C. increase sweep speed of the recorder
D. adjust the baseline of the tracing
A
A
PPG exams should be performed in a warm room. The digits can be warmed to increase pulse amplitude. A towel can be used to cover the digits and sensors to warm the digits and reduce effects of surrounding light. The sweep speed effects the display of volume changes over time, not amplitude of the tracing. The baseline is used to indicate positive or negative direction of flow. Changes in baseline are used to highlight flow patterns toward or away from the transducer.
14
Q
Which of the following is a reason to perform exercise with a segmental pressure exam?
A. to differentiate an SFA stenosis from an occlusion
B. to evaluate volume changes in the limb
C. to differentiate true claudication from pseudoclaudication
D. to evaluate the effects of vasoconstriction
A
C
True claudication will be associated with a decrease in ABI with exercise. Pseudoclaudication will be associated with no change in the ABI with exercise.
15
Q
What can be done to inhibit light from the exam room from causing artifact on an upper extremity PPG tracing?
A. cover the patient’s hand with a towel or sheet
B. perform the exam with all lights off and windows covered
C. increase the room temperature
D. place acoustic gel between the PPG sensor and the skin
A
A
To reduce light from the exam room from causing artifact on the PPG tracing, cover the patient’s hand with a towel or sheet.
16
Q
A patient presents with left leg claudication. The right ABI is 1.13 and the left ABI is 1.37. What should you do next for this patient?
A. put the patient on the treadmill and repeat the ABI for both legs
B. end the exam and record the findings
C. stop the segmental pressure exam and obtain toe pressures along with PVR waveforms
D. switch to 16cm thigh cuffs and continue the segmental exam to include the proximal calf and thigh pressures
A
C
When the ABI exceeds 1.3, there is most likely medial calcification present. Because medial calcification does not usually affect the smaller digital arteries, the toe pressures can be obtained. PVR waveforms can be obtained to locate the obstruction, if the TBI is abnormal.
17
Q
Which of the following is not proper procedure for a venous PPG evaluation of the legs?
A. patient is seated with legs dangling over edge of bed for the exam
B. Always place the sensor over the largest varicose vein in the calf
C. the optimal speed for the strip chart recorder is 5mm/sec
D. a tourniquet is applied to the leg after initial testing shows a VRT < 20 sec
A
B
Patient is seated with legs dangling over edge of bed for the exam. A sensor is placed on the distal medial lower leg. Never place the PPG sensor on an open wound, ulcer or varicose vein. A strip chart recorder documents flow changes. The optimal speed for the strip chart recorder is 5mm/sec. A tourniquet is applied to the leg after initial testing shows a VRT < 20 sec.
18
Q
When performing an upper extremity segmental pressure exam, you obtain the following reading on the right arm. Right upper arm 140mmHg, right radial artery 110mmHg, right ulnar artery 130mmHg. Which of the following correctly explains the findings? A. subclavian artery obstruction B. radial artery disease C. distal brachial artery obstruction D. radial and ulnar artery disease
A
B
There is a 30mmHg drop in pressure between the upper arm and the radial artery at the forearm. This indicates radial artery disease. The ulnar artery pressure is only mildly decreased and does not indicate disease. A brachial obstruction would affect the pressure in both of the forearm arteries.
19
Q
The following pressure readings from a segmental pressure evaluation were obtained in a patient suffering from low back and thigh pain. What is the ABI for each leg?
Lt Ankle 136
Rt Ankle 128
Lt Arm 124
Rt Arm 120
A. Rt = 1.03, Lt = 1.10
B. Rt = 1.03, Lt = 1.13
C. Rt = 1.07, Lt = 1.10
D. Rt = 0.94, Lt = 0.91
A
A
Rt ABI = 128/124 = 1.03
Lt ABI = 136/124 = 1.10
20
Q
The following pressure readings from a segmental pressure evaluation were obtained in a patient suffering from low back an thigh pain when walking. Which of the following describes a possible reason for the patient’s symptoms?
Lt Ankle 136
Rt Ankle 128
Lt Arm 124
Rt Arm 120
A. neurogenic claudication
B. stenosis of the external iliac artery
C. May Thurner syndrome
D. stenosis of the common femoral artery
A
A
When lower extremity symptoms are caused by ambulation and the ABI exam is normal, the symptoms are called pseudoclaudication or neurogenic claudication. The most common cause of pseudoclaudication due to lumbar spinal stenosis, a condition that occurs when the spaces narrow between the vertebrae in your lower back.
21
Q
A diabetic patient presents for a segmental pressure exam. The patient complains of an injury to his big toe that won't seem to heal and has been open for over 3 weeks. The digital pressure in the affected toe will most likely be \_\_\_\_\_\_\_. A. <30mmHg B. 60-90mmHg C. >200mmHg D. 30-60mmHg
A
A
Toe pressures <30mmHg correlate with a non-healing wound.
22
Q
A patient comes in late for his scheduled exam and states he walked to the facility after his car broke down. Registration passes him through to the vascular department and he is still slightly SOB. What is the first thing you should do when starting his exam?
A. take his brachial pressures
B. have him lie down and start with the Duplex exam and perform the pressures later
C. Take his ankle pressures using the PTA and DPA
D. have him rest for 20-30 minutes to allow flow in the legs to normalize
A
D
If the patient does not rest, the exercise from his long walk can affect the results of the expected resting arterial exam. This can lead to overestimation of the severity of the disease identified on the resting exam.
23
Q
It is important to wait at least one minute before repeating what measurement?
A. brachial pressure on an arm with a hemodialysis graft
B. volume flow in a hemodialysis graft
C. ankle blood pressure
D. MCA mean velocity
A
C
When you are obtaining a blood pressure for a second time, it is important to wait at least 1 minute between cuff inflations. Pressure results may be inaccurate if the system is not given the opportunity to normalize after the first pressure measurement. NEVER perform a blood pressure assessment on an arm with a hemodialysis graft.
24
Q
What are the average treadmill settings utilized in exercise testing? A. 5mph at 10% grade B. 2mph at 12% grade C. 3mph at 8% grade D. 5mph at 12% grade
A
B
The average treadmill settings utilized in exercise testing is 2mph speed at 12% grade.
25
```
When evaluating suspected thoracic outlet syndrome, a PPG exam can be performed with the sensor placed on the ________ or a Doppler exam can be performed with the transducer placed __________.
A. lateral wrist, on the brachial artery
B. 2nd digit, on the radial artery
C. 1st digit, on the carotid artery
D. medial wrist, on the radial artery
```
B
When evaluating suspected thoracic outlet syndrome, a PPG exam can be performed with the sensor placed on the 2nd digit or a Doppler exam can be performed with the transducer placed on the radial artery.
26
```
Lower extremity arterial segmental pressure exam results in a post exercise basal pressure recovery time of > 6 minutes which suggests:
A. popliteal entrapment syndrome
B. single level stenosis
C. iliac disease
D. multi-level stenosis
```
D
Lower extremity arterial segmental pressure exam resulting in a post exercise basal pressure recovery time of 2 to 6 minutes suggests single level disease. Lower extremity arterial Doppler exam resulting is a post exercise basal pressure recovery time greater than 6 minutes suggests multi-level disease.
27
Which of the following is NOT an appropriate reason to terminate the treadmill exercise for a lower extremity arterial exam?
A. patient complains of chest pain
B. patient complains that the treadmill is too noisy
C. patient complains of shortness of breath
D. patient complains of leg pain
B
Anytime the patient reports symptoms of pain in the legs or the chest, the exam should be terminated. Never try to talk the patient into continuing the exam. Always record the duration of the exercise, location of the symptoms and changes in ankle pressures.
28
A normal extremity arterial response to reactive hyperemia is:
A. <35% increase in ankle pressures that return to normal within one minute
B. no change is ankle pressures
C. <50% drop in ankle pressures
D. <35% drop in ankle pressures that return to normal within 1 minute
D
A normal lower extremity arterial response to reactive hyperemia is <35% drop in ankle pressures that return to normal within 1 minute.
29
Which of the following describes an Air Plethysmography exam that is positive for venous insufficiency?
A. after the patient performs 40 toe raises, the venous filling index will decrease under the cuff
B. after the legs are elevate and then the patient stands, the venous filling index will be increased
C. recording demonstrates large changes in blood volume in the area of the leg under the cuff
D. APG is not performed to assess venous insufficiency
B
An APG exam is performed by placing a large cuff around the calf. The leg is elevated until the plethysmographic tracing plateaus indicating the veins have emptied. The patient will then quickly stand up to assess the rate of venous refill under the cuff. A fast refill time occurs with valvular insufficiency. A VRT greater than 20 seconds is considered normal. The venous refill index is measured in mL/sec. VFI = 90% venous refill volume divided by time it took to reach 90% volume. Slower refill rates are normal. VFI <2mL/sec is normal; >7mL/sec indicates severe insufficiency.
30
The 12cm blood pressure cuffs are missing from the lab. You perform the 3 cuff method lower extremity segmental pressure exam with the 10cm cuffs on a patient that is 5'5" 150lbs. What information that you will report will be invalid?
A. calf pressure only
B. brachial pressure, calf pressure and ankle pressure
C. brachial pressure only
D. thigh pressure only
D
The 12cm cuff is normally used for the thigh. If the smaller cuff is used, the pressure will be overestimated in the thigh.
31
Which of the following is a normal response from the capillary beds of the feet and ankles after 5 minutes of vigorous exercise?
A. vasoconstriction
B. increased osmotic pressures
C. no change in the flow in normal vessels
D. vasodilation
D
Resistance decreases in the capillary beds to allow an increase in flow volume with exercise. Normal arteries do not demonstrate any change in pressure with exercise.
32
When performing a treadmill test for PAD, exercise is normally performed ______. When performing a reactive hyperemia exam for PAD, the cuffs are inflated ________.
A. with the patient standing, with the patient supine
B. with the patient supine, with the patient standing
C. for up to 5 minutes, for up to 5 minutes
D. for up to 10 minutes, for up to 5 minutes
C
When performing a treadmill test for PAD, exercise is normally performed for up to 5 minutes. When performing a reactive hyperemia exam for PAD, the cuffs are inflated for up to 5 minutes. If the patient experiences symptoms, the exam can be terminated earlier.
33
```
Which of the following is performed with the patient sitting upright?
A. penile Doppler exam
B. pressure evaluation of the toes
C. PVR evaluation of the toes
D. pressure evaluation of the fingers
```
D
| Finger pressures should be obtained with the patient sitting upright, hand placed on a positioning wedge or pillow.
34
When performing a lower extremity venous Doppler for insufficiency,
A. the intensity of the Doppler signal indicates the severity of the reflux
B. augmentation pressure is applied quickly, held for at least 15 seconds, and released quickly
C. a minimum of 30 seconds between augmentation maneuvers is recommended
D. the GSV should be evaluated with patient bearing weight on the leg
C
When performing a lower extremity venous Doppler for insufficiency, a minimum of 30 seconds between augmentation maneuvers is recommended. The veins need sufficient time to refill before augmentation is repeated.
35
A patient presents with a history of HTN, DM and claudicaton. The arterial Doppler evaluation demonstrates monophasic flow in all vessels but the ABI values are LT 1.36 and RT 1.32. Which of the following correctly describes the findings?
A. the exam is normal and additional testing should be performed to rule out extrinsic vessel compression due to popliteal entrapment syndrome
B. the most likely diagnosis is thromboangiitis obliterans, which leads to medial calcification of the calf vessels
C. the exam is normal and additional testing should be performed to rule out extrinsic vessel compression due to median arcuate ligament syndrome
D. the ABI values are abnormally elevated due to a diabetic complication called medial calcification
D
Monophasic flow in the extremities is normally accompanied with an ABI less than 0.9. Diabetes can lead to medial calcification of the arterial walls which will falsely elevate the ankle pressures.
36
```
Which of the following screening techniques for peripheral arterial disease can distinguish between a stenosis and an occlusion in a vessel?
A. segmental pressure evaluations
B. Doppler evaluations
C. pulse volume recording
D. photoplethysmography
```
B
Segmental pressure and PVR exams can only detect the decrease in flow volume to the legs at a general location in the leg. The results do not provide information on specific vessels, nor can they distinguish stenosis from occlusion.
37
A segmental pressure exam demonstrates the following pressures; distal thigh 144, calf 166, ankle 132. Which of the following could explain these results?
A. medial calcification or venous insufficiency
B. incorrect cuff size would be the only possible cause
C. improper cuff placement and incorrect cuff size, but not medial calcification
D. incorrect cuff size, medial calcification and improper cuff placement
D
The calf pressure should not demonstrate an increased pressure related to the thigh pressure. All of the choices can lead to an overestimated pressure measurement.
38
```
When evaluating arterial pressures in the toes, the patient should be:
A. standing
B. sitting
C. supine
D. walking
```
C
| Arterial pressures should be evaluated with the patient supine to eliminate the effects of hydrostatic pressure.
39
Which of the following is considered a limitation of the three cuff lower extremity segmental pressure exam?
A. the single thigh cuff normally overestimates the thigh pressure
B. there is no way to differentiate groin and ankle arterial disease
C. there is no way to differentiate lower thigh and popliteal arterial disease
D. there is no way to differentiate proximal and distal calf artery disease
C
Because there is only one cuff on the thigh, there is no way to differentiate disease in the lower thigh from disease in the popliteal artery. The pressure is obtained mid-thigh and calf. The distal SFA and popliteal artery could have disease if the calf pressure is decreased.
40
```
Where is the recommended placement for the pneumatic cuff when using a rapid cuff inflator to evaluate the distal femoral vein and great saphenous vein?
A. distal thigh
B. upper calf
C. foot/metatarsals
D. ankle
```
B
When evaluating a patient for insufficiency, a rapid cuff inflator can be used for a consistent augmentation of each vessel. The cuff is usually placed just distal to the area of interest. 70 to 80mmHg of pressure is applied quickly, held for a few seconds, and released quickly. Reversal of flow is assessed after release of the augmentation compression. Veins distal to the cuff can also be evaluated using proximal augmentation. Flow reversal would be documented during the compression part of the augmentation.
41
```
A patient complains of left arm numbness and pain that increases in severity when it is cold outside. An upper extremity arterial duplex exam demonstrates a >50% stenosis in the distal subclavian artery. The PPG exam demonstrates additional decrease in digital flow with cold exposure. What explains these findings?
A. Buerger Disease
B. Thoracic Outlet Syndrome
C. Primary Raynaud Syndrome
D. Secondary Raynaud Syndrome
```
D
Changes in flow patterns in the hand due to the application of external stimuli (cold) are a characteristic sign of Raynaud Disease. Secondary Raynaud Phenomenon refers to these changes that occur in conjunction with a diseased arterial system in the upper extremity. Primary Raynaud Syndrome refers to these changes that occur in conjunction with a non-diseased arterial system in the upper extremity.
42
Treadmill exercise is normally performed:
A. until symptoms are intolerable
B. up to 12 minutes or until symptoms are intolerable
C. up to 5 minutes
D. until symptoms are intolerable or up to 5 minutes
D
| Treadmill exercise is normally performed until symptoms are intolerable or up to 5 minutes.
43
Venous PPG tracings are obtained. The right side demonstrates a venous refill time of 14 seconds. The left side demonstrates a refill time of 23 seconds. Which of the following describes the next step in evaluation?
A. a tourniquet will be applied to the left leg at the thigh level and the VRT assessment will be repeated
B. a tourniquet will be applied to the right leg at the thigh level and the VRT assessment will be repeated
C. a tourniquet will be applied to both legs at the thigh level and the VRT assessment will be repeated
D. the results are normal. No further evaluation is necessary.
B
The left side demonstrates a normal VRT > seconds. The right leg requires evaluation with a tourniquet. If the VRT returns to a level above 20 seconds, this indicates the insufficiency is in the superficial system. If the VRT remains abnormal with the superficial system "cut off" by the tourniquet, this indicates deep venous system insufficiency.
44
```
Photoplethysmography uses _________ to detect changes in venous volume in the leg.
A. mercury tubing
B. light
C. sound waves
D. air
```
B
| Photoplethysmography uses light to detect changes in venous volume in the leg.
45
Which blood vessel is most commonly evaluated with Doppler to obtain the thigh pressure when performing a segmental pressure exam?
A. femoral artery just distal to the thigh cuff
B. distal calf artery with highest ankle pressure
C. distal calf artery with lowest ankle pressure
D. popliteal artery just above the calf cuff
B
The PTA or DPA that yields the highest pressure at the ankle should be used to obtain the pressures for the remaining arterial segments.
46
A patient presents with a history of recurrent upper extremity DVT due to Paget Schroetter syndrome. The referring physician ordered a PVR exam of the upper extremities instead of a venous Doppler exam of the upper extremities. Why?
A. to rule out associated atherosclerotic disease
B. to rule out Raynaud's syndrome
C. to rule out a subclavian steal
D. to rule out thoracic outlet syndrome
D
Paget Schroetter syndrome is commonly associated with thoracic outlet syndrome. The presence of a cervical rib or aberrant muscle band can be involved with the DVT formation with Paget Schroetter syndrome.
47
```
A patient presents for an exercise arterial exam after an abnormal resting exam. The report for the resting exam describes: elevated velocities that indicate a stenosis of >50% in the distal femoral artery on the left leg, biphasic waveforms in the PTA and DPA and an ABI of 0.96. There is no change in the waveforms or decrease in ankle pressures in the left leg with exercise. What could explain these findings?
A. obstructed venous outflow
B. Raynaud syndrome
C. congestive heart failure
D. extensive collateral formation
```
D
Exercise induces peripheral vasodilation. If collateral flow is present, it will compensate for the expected drop in flow and pressure from a diseased vessel.
48
Which of the following would cause the systolic pressure reading obtained from the below knee cuff to be falsely elevated?
A. cuff is too large
B. cuff placement over the tibial tubercle
C. the patient suffers from congestive heart failure
D. reading obtained with the patient supine
B
The bladder of the cuff must be placed over the artery being evaluated and only compress soft tissue, not bony structures. The below-knee or upper calf cuff should be placed just distal to the tibial tubercle or pressure readings will be falsely elevated. Other causes of falsely elevated pressure readings include medial calcification, cuff too loose, cuff too small, patient not supine (hydrostatic pressure).
49
You are preparing for a lower extremity segmental pressure exam on a patient with leg pain. She was admitted to the hospital 2 days ago due to extensive lower extremity DVT. How will you proceed?
A. obtain Doppler waveforms and toe-brachial indices
B. check the chart for anticoagulant medication and if it is listed, proceed normally with the exam
C. cancel the exam
D. use cuffs only over areas of the leg where DVT was not identified
A
If a patient has suspected or known acute deep venous thrombosis, use waveform analysis only and/or use toe/brachial indices (TBI). Never place cuffs on a leg with DVT. You could easily cause and embolism with the cuff pressure. Anticoagulant therapy helps to prevent propagation of the clot, it does not provide thrombolytic therapy. The DVT found 2 days ago cannot have recanalized in such a short period of time. A Sonographer should never cancel and exam without referring physician approval.
50
```
The difference in systolic pressure between two adjacent levels in the same leg should be no more than ________mmHg.
A. 15
B. 20
C. 25
D. 30
```
D
| A drop in pressure of 30mmHg or more between segments indicates disease between the two segments.
51
```
A double peaked waveform obtained during PPG evaluation of the digits of the left hand is indicative of:
A. Raynaud syndrome
B. palmar arch stenosis
C. thoracic outlet syndrome
D. subclavian stenosis
```
A
| The double peaked PPG tracing is indicative of vasospasm seen with Raynaud syndrome.
52
```
Photoplethysmography (PPG) is useful to assess all of the following, except:
A. digit perfusion
B. thoracic outlet syndrome (TOS)
C. Raynaud disease
D. subclavian steal
```
D
PPG or photoplethysmography is very useful for evaluating flow into the digital vessels. Raynaud disease most commonly affects the smaller vessels of the hands. Thoracic outlet syndrome usually causes an obstruction of the upper extremity arterial flow, which could be demonstrated by using the PPG technique to assess digital perfusion.
53
An upper extremity segmental pressure exam produces the following pressures:
Brachial RT 140mmHg AND LT 132mmHg
Radial RT 144mmHg AND LT 136mmHg
Ulnar RT 138mmHg AND LT 138mmHg
2nd Digit RT 130mmHg AND LT 104mmHg
What should you do next for this patient?
A. end the exam and report right palmar arch disease
B. perform digital pressures on at least one more digit on the right hand
C. perform digital pressures on at least one more digit on the left hand
D. end the exam and report left palmar arch disease
C
When the arm pressures are normal but the digital pressure is abnormally reduced, there could be disease in the palmar arch or the single digit. To provide a complete evaluation, at least one more digit and the left hand should be evaluated. If the additional digit pressure is abnormal, disease in the palmar arch is the most likely cause for the reduced digit pressures. If the additional digit pressure is normal, the remaining digits should be tested to confirm that the reduced pressure is limited to the single digit and disease of that digital artery should be suspected.
54
```
If the systolic brachial pressure is 116mmHg, the toe pressure would be considered normal if it is _______ or greater.
A. 80mmHg
B. 60mmHg
C. 100mmHg
D. 70mmHg
```
D
The normal pressure in the lower extremity digits is normally at least 60% of the brachial pressure. 116 x 0.60 = 70mmHg. The toe pressure is considered normal if it is 70mmHg or higher.
55
```
How many cuffs are recommended when performing a bilateral lower extremity segmental pressure evaluation?
A. 3
B. 5
C. 4
D. 8
```
D
| The most common protocol for a segmental pressure exam of both of the legs involves 4 cuffs per leg for a total of 8.
56
Which of the following indicates single level arterial obstruction in the leg?
A. ABI >0.5
B. velocity of 200cm/s or less
C. post exercise ankle recovery time 6-12 minutes
D. ABI <0.5
A
| ABI >0.5 single level disease; ABI <0.5 multi-level disease
57
The 10cm blood pressure cuffs are missing from the lab. You perform the 3 cuff method lower extremity segmental pressure exam with the 12cm and 14cm cuffs on a patient that is 5'5" 150lbs. What information that you will report will be invalid?
A. brachial pressure only
B. brachial pressure, calf pressure and ankle pressure
C. calf pressure only
D. thigh pressure only
B
The 12cm or larger cuff is normally used for the thigh. If the larger cuff is used, the pressure will be underestimated in the calf, ankle and arm.
58
You are performing an upper extremity segmental pressure evaluation and obtain the following information:
Brachial 140mmHg.
Upper forearm 132mmHg
Wrist - Radial 108mmHg
Wrist - Ulnar 130mmHg
Which of the following correctly describes the findings?
A. obstruction of the mid radial artery
B. subclavian steal
C. obstruction of the mid ulnar artery
D. obstruction of the distal brachial artery
A
The brachial and upper forearm pressure is normal, but there is a 22mmHg difference between the radial and ulnar pressures. The vessel with the lower pressure has an obstruction proximal to the wrist.
59
What is the primary purpose of using a tourniquet during a venous PPG exam of the leg?
A. to determine if thrombus is confined to the superficial system
B. to evaluate the perforators for reflux
C. to determine if thrombus is present in the deep or superficial system
D. to determine if venous insufficiency is confined to the superficial system
D
When the venous refill time (VRT) is less than 20 seconds, a tourniquet is applied to the leg at the groin to occlude superficial venous flow. The VRT is re-evaluated and if it is now >20 seconds, the insufficiency is only present in the superficial system. If the VRT does not return to normal, the insufficiency is in the deep system (and possibly the superficial system),
60
A patient presents for a bilateral segmental pressure exam and complains of mild leg pain since their heart attack last year. The recorded pressures are as follows:
Right Arm 110mmHg, Right PTA 88mmHg, Right DPA 92mmHg
Left Arm 105mmHg, Left PTA 90mmHg, Left DPA 94mmHg
The doctor orders a duplex exam to follow which shows medium velocity, triphasic flow with minimal atherosclerosis in the bilateral arteries. Which of the following could explain the findings?
A. the normal arterial duplex exam correlates with the normal lower extremity segmental exam with right ABI 1.20 and left ABI 1.17
B. the patient most likely has reduced cardiac output causing the right ABI 0.84 and left ABI 0.85
C. the patient is most likely suffering from Buerger disease
D. the patient most likely has reduced cardiac output causing the right ABI 0.8 and left ABI 0.82
B
Reduced cardiac function with heart failure will lead to reduced pressures distally. Right ABI = 92 / 110 = 0.84; Left ABI = 94 / 110 = 0.85; always use the highest ankle pressure on each leg and use the higher of the two brachial pressures.
61
Which of the following statements is true regarding a PPG exam for venous insufficiency?
A. prolonged venous refill time (>20s) indicates competent venous valves
B. tourniquets are used in conjunction with PPG exam to depict the extent of DVT
C. the best readings with severe insufficiency will be obtained at an ulceration site
D. waveforms obtained for a venous PPG exam are similar to those obtained in a venous duplex exam
A
PPG sensors must be placed on areas of intact skin. Tourniquets are used in conjunction with PPG exam to depict the extent of venous insufficiency. Longer VRT values are desired, short refill times indicate reflux of venous outflow.
62
```
Which of the following disorders would demonstrate normal digital pressures in the upper extremity?
A. SVC syndrome
B. thoracic outlet syndrome
C. Buerger disease
D. Raynaud disease
```
A
Raynaud, TOS, Buerger disease and atherosclerosis can all lead to abnormally low digit pressures and abnormal PPG tracing.
63
The following pressures were obtained in a patient during a segmental pressure exam. Where is the disease, if any?
Right: PTA 136mmHg, DPA 130mmHg, Calf 136mmHg, Low Thigh 144mmHg, High Thigh 160mmHg, Brachial 130mmHg
Left: PTA 98mmHg, DPA 85mmHg, Calf 100mmHg, Low Thigh 114mmHg, High Thigh 128mmHg, Brachial 126mmHg
A. normal left leg, medial calcification right leg
B. iliac disease left leg, normal right leg
C. left calf artery disease, normal right leg
D. aortic disease or left iliac disease
B
The left ABI value is reduced at 0.75. When using 4 cuffs, the high thigh pressure is normally 30-40mmHg higher than the brachial pressure. The other pressures in the leg do not demonstrate a significant drop between consecutive segments. There is iliac disease that is causing the decrease in the pressures in the entire leg. If aortic disease was present, both legs would be affected.
64
Which of the following could cause a false reduction in ankle pressure on an average sized patient?
A. medial calcification of the calf vessels
B. cuff is loosely wrapped around the arm
C. using the 12cm cuff for the ankle
D. evaluating the pressure with the patient seated in a chair
C
False elevation of the ankle pressure = medial calcification, cuff too loose, cuff too small, patient not supine (hydrostatic pressure).
False reduction in the ankle pressure = cuff too large, congestive heart failure, coarctation
65
Which of the following is a contraindication for a lower extremity segmental pressure exam?
A. diabetes mellitus
B. current anticoagulant treatment
C. ulceration on the 3rd and 4th toes
D. recent saphenous vein arterial bypass grafting
D
Contraindications:
Suspected or known acute deep venous thrombosis - use waveform analysis only or use of a toe-brachial index (TBI)
Recent surgery, trauma site or ulcers that cannot/should not be compressed by pressure cuffs
History of lower limb stent replacement, or recent saphenous vein arterial bypass grafting
Patients with incompressible arteries due to medial calcification - TBI may be used instead
Morbidly obese patients - high-thigh pressure may be unobtainable or inaccurate due to limb girth
Patients with significant tremors or involuntary movements that may cause waveforms to be suboptimal or unreliable
Ulcerations on the 3rd and 4th toes would not be compressed by cuffs. While diabetes mellitus can cause medial calcification which could inhibit the exam, not every patient with DM has medial calcification.
66
An arterial duplex exam demonstrates monophasic flow in the popliteal and calf arteries. The bilateral ABI calculations are over 1.0. What type of testing can be used to better evaluate the pressures in the lower extremities in this patient?
A. repeat the ABI using smaller width of cuff to reduce the peak pressure obtained
B. impedance plethysmography
C. repeat the ABI using larger width of cuff to reduce the peak pressure obtained
D. digit plethysmography
D
| Digital PPG can be performed to evaluate flow and systolic pressure measurements of the toes can be performed.
67
```
Which of the following techniques can be used to assess the presence and timing of reflux in multiple vessels simultaneously?
A. CW Doppler
B. color Doppler
C. real time 2D imaging
D. PW Doppler
```
B
A transverse view can demonstrate the GSV and one of its tributaries. Color Doppler with augmentation can demonstrate the presence and timing of reflux in both veins. This is very helpful in identifying recirculating reflux.
68
```
When a patient performs exercise on a treadmill what will be the normal change in arterial flow in the legs?
A. increased antegrade flow in diastole
B. decreased antegrade flow in diastole
C. increased peripheral resistance
D. unchanged flow pattern
```
A
When the patient exercises, the leg muscles require more blood flow for proper operation. The resistance will drop at the ankle to allow the increased flow in diastole.
69
```
The ankle brachial index is commonly performed as part of which of the following exams?
A. transcutaneous oximetry
B. exercise testing
C. photoplethysmography
D. strain gauge plethysmography
```
B
| The ABI is performed at rest and with exercise. If the ABI decreases with exercise, arterial disease is present.
70
A segmental pressure exam demonstrates the following pressures; right arm: 136mmHg; right leg: thigh 110mmHg, calf 100mmHg, ankle 92mmHg. Which of the following could explain these results?
A. aortic disease or popliteal disease
B. common iliac disease or distal femoral artery
C. medial calcification
D. aortic disease or common iliac disease
D
The pressures in the entire leg are decreased which indicates proximal disease. Using the three cuff method, the brachial pressure and thigh pressure are usually relatively the same. If the left leg is affected also, aortic disease is the most likely diagnosis. If only the right leg is affected, then the cause is related to common iliac disease.
71
```
When using the 4 cuffs method to obtain segmental pressures in the legs, the blood pressure in the proximal thigh normally exceeds the brachial systolic pressure by _______mmHg.
A. 10-20
B. 20-30
C. 30-40
D. 40-50
```
C
When performing the four cuff method of obtaining segmental pressures, the blood pressure in the proximal thigh normally exceeds the brachial systolic pressure by 30-40mmHg. The three cuff method yields a thigh pressure that should be equivalent to the brachial pressure in a normal pressure.
72
```
Which of the following exams does not use PW or CW Doppler?
A. pulse volume recording
B. periorbital exam
C. extracranial exam
D. transcranial exam
```
A
| Pulse volume recording is performed using blood pressure cuffs to measure volume changes under the cuffs.
73
```
Subcutaneous blood supply to the digits can be evaluated using which non-invasive plethysmography technique?
A. impedance plethysmography
B. strain gauge plethysmography
C. pulse volume recording
D. photoplethysmography
```
D
Photoplethysmography uses photocells to detect the changes in blood cell volume in subcutaneous tissue during the cardiac cycle.
74
What is the most accurate method of thigh pressure assessment?
A. 3 cuff segmental pressure exam
B. Doppler velocity used in the Bernoulli equation to calculate thigh pressure
C. intravenous catheter measures pressure in the superficial femoral vein
D. 4 cuff segmental pressure exam
A
The 4 cuff method uses two smaller cuffs to obtain two separate thigh pressures. These cuffs are usually smaller than the thigh cuff used in the 3 cuff method. Smaller cuffs tend to overestimate the thigh pressure. The larger cuff used in the 3 cuff method provides a more accurate pressure.
75
What is the normal change in flow velocity in response to releasing the cuff during reactive hyperemia?
A. increase by more than 35% above the resting flow velocity
B. increase to more than double the resting flow velocity
C. decrease to less than half of the resting flow velocity
D. decrease by more than 35% below the resting flow velocity
B
The normal initial flow response to reactive hyperemia should include a flow velocity that is more than double the resting flow velocity.
76
Abnormal results for an arterial segmental pressure evaluation with exercise will include which of the following characteristics?
A. 50% or greater decrease in ankle pressure post-exercise with basal pressure recovery time < 3min
B. 25% or greater decrease in ankle pressure post-exercise with basal pressure recovery time > 3 min
C. 25% or greater increase in ankle pressure post-exercise with basal pressure recovery time > 3 min
D. 75% or greater decrease in ankle pressure following exercise with basal pressure recovery time < 3 min
B
In patients with hemodynamically significant stenosis, ankle pressures will drop greater than 25% with exercise. The pressures will return to pre-exercise levels but it will take longer than 3 minutes to normalize.
77
Increased peripheral resistance will lead to ______ amplitude in PVR tracings.
A. increased
B. decreased
C. little change in
A
78
```
When performing a photoplethysmography exam for arterial insufficiency, where should you place the sensor?
A. groin
B. dorsal aspect of the great toe
C. distal pad of the great toe
D. medial distal calf
```
C
Venous insufficiency is assessed by placing the sensor on the distal calf. Arterial disease is assessed by placing the sensor on the pads of the toes.
79
When the Allen test is performed with significant abnormal findings, what happens to the digit PPG tracings with radial artery compression?
A. amplitude increases by at least 4 times the original amplitude
B. amplitude significantly decreases
C. dicrotic notch moves to the top of the peak amplitude
D. amplitude increases by at least 50%
B
If the Allen test provides abnormal results, the palmar arch is not patent because the ulnar artery is obstructed. When the radial artery is compressed, there is little to no flow reaching the hand.
80
```
Which of the following describes the expected change in the PVR tracing on an immediate post procedure evaluation of a patient after successful revascularization of the common femoral artery?
A. increased amplitude by >100%
B. decreased amplitude by >50%
C. increased amplitude by >50%
D. loss of the dicrotic notch
```
C
Normal PVR tracings from an extremity should be high amplitude with a dicrotic notch. If the revascularization was a success, the amplitude of the waveform should have increased at least 50% compared to the amplitude on the pre-op exam.
81
Which of the following correctly describes normal results for an air plethysmography (APG) exam?
A. high ejection fraction, with low residual venous fraction and venous filling index
B. high ejection fraction and residual venous fraction with low venous filling index
C. low ejection fraction and low residual venous fraction with high venous filling index
D. low ejection fraction, low residual venous fraction and venous filling index
A
Most blood should be ejected out of the leg with calf contraction (high EF%). The VFI is the rate of venous filling. Slower fill rates indicate normal veins. Residual Venous Fraction is the % of venous volume remaining after tiptoe exercises. Low RVF% of blood should remain in the leg with calf contraction.
82
```
Flow velocity in a lower extremity arterial bypass graft is considered abnormal once it falls below ________.
A. 40cm/s
B. 60cm/s
C. 30cm/s
D. 50cm/s
```
A
| If the flow velocity in a lower extremity arterial bypass graft falls below 40cm/s, graft failure is suspected.
83
Which method is preferred to evaluate suspected popliteal entrapment?
A. pulse volume recordings of the leg arteries with the patient supine and standing
B. PPG tracing of the digits at rest and during dorsiflexion
C. segmental pressures before and after treadmill exercise
D. PPG tracing of the digits at rest and during treadmill exercise
B
Evaluation of a patient with suspected popliteal entrapment should be performed using PPG sensors to record changes in flow during calf contraction. Active plantar or dorsiflexion of the foot can be performed to cause controlled calf muscle contraction.
84
```
The lower extremity segmental pressure exam is most commonly performed with a/an ____________ to obtain the Doppler signal for the pressure measurements at the ankle.
A. 8-10MHz vector array
B. 5-7MHz linear array
C. 2-3MHz CW Doppler probe
D. 8-10MHz CW Doppler probe
```
D
The dedicated CW probe is used to obtain the Doppler signal at the ankle while pressure measurements are obtained in the leg.
85
An upper extremity segmental pressure exam produces the following pressures:
Brachial RT 140mmHg, LT 132mmHg
Radial RT 144mmHg, 136mmHg
Ulnar RT 138mmHg, LT 128mmHg
2nd Digit RT 130mmHg, LT 104mmHg
Which of the following correctly describes how to report the findings?
A. suspected disease of the proximal left radial artery
B. suspected disease of the right palmar arch or digital artery of the second digit
C. suspected disease of the left palmar arch of digital artery of the second digit
D. suspected disease of the proximal left ulnar artery
C
When the arm pressures are normal but the digital pressure is abnormally reduced, there could be disease in the palmar arch of the single digit. To provide a complete evaluation, at least one more digit on the left hand should be evaluated. If the additional digit pressure is abnormal, disease in the palmar arch is the most likely cause for the reduced digit pressures. If the additional digit pressure is normal, the remaining digits should be tested to confirm that the reduced pressure is limited to the single digit and disease of that digital artery should be suspected.
86
A patient with a history of HTN, DM and coronary artery disease complains of bilateral rest pain relieved by dangling legs over the edge of the bed. The 4th and 5th toe on the left foot have blackened tips. Bilateral thickened toenails, very dry skin and hair loss are also noted on physical exam. The right ankle pressure is 148mmHg and the highest arm pressure is 140mmHg. Which statement is true regarding these findings?
A. the signs and symptoms are most likely related to associated venous insufficiency
B. the signs and symptoms are most likely related to dehydration and poor hygiene
C. an exercise arterial exam is necessary to properly diagnose the patient
D. toe pressures should be obtained for further evaluation
D
Medial calcification does not always cause an excessive ABI measurement of greater than 1.30. The symptoms of significant ischemia do not fit the normal ABI measurements. The diabetic history also adds to the risk for the medial calcification. Toe pressures and/or PPG or PVR evaluation will provide better information on this patient.
87
```
An abnormal penile/brachial index will be:
A. <1.0
B. >1.0
C. <0.65
D. >0.65
```
C
| If the penile blood pressure is less than 65% of the systemic pressure, vasculogenic impotence is diagnosed.
88
Which of the following is a contraindication for exercise testing?
A. non-compressible calf arteries
B. history of cardiac procedure or myocardial infarction
C. systemic HTN with systolic pressure >200mmHg
D. more than one of the above
D
Contraindications for Exercise Testing:
Known disease in one extremity that is untreated
Inability to walk without assistance
History of stroke with residual paralysis
Shortness of breath
Low exercise tolerance
Systemic HTN with systolic pressure >200mmHg
Noncompressible calf arteries
Unstable angina and/or use of nitroglycerin for chest pain
History of cardiac procedure or myocardial infarction - must be cleared for exercise testing by cardiologist
89
```
Which extremity arterial evaluation technique can be described as the placement of multiple cuffs around the extremity that measure the volume changes beneath them?
A. pulse volume recording
B. segmental pressures
C. impedance plethysmography
D. photoplethysmography
```
A
Pulse volume recording is a type of plethysmography exam used to evaluate the arterial inflow of an extremity. Partially inflated cuffs placed on the extremity at different levels record the volume changes on a strip chart recorder. The higher the amplitude of the analog signal, the better the arterial inflow under that cuff.
90
The PVR tracing from the proximal thigh demonstrates a tracing with high amplitude peak and dicrotic notch. The tracing from the distal thigh demonstrates a reduced amplitude tracing with loss of the dicrotic notch. Which of the following explains these findings?
A. unable to determine with PVR tracing from the calf
B. stenosis proximal to the proximal thigh cuff
C. stenosis distal to the distal thigh cuff
D. stenosis distal to the proximal thigh cuff
D
When a PVR tracing is reduced in amplitude, demonstrates a rounded peak and absence of the dicrotic notch, stenosis proximal to the cuff is suspected.
91
Which of the following is a major limitation of a lower extremity segmental pressure exam when compared to a Doppler evaluation?
A. the segmental pressure technique cannot differentiate external iliac from common femoral stenosis/occlusion
B. the segmental pressure technique is only valid for evaluating obstructive disease above the knee
C. the segmental pressure technique cannot evaluate obstructive disease in the feet
D. the segmental pressure technique is only valid for evaluation obstructive disease below the knee
A
Segmental pressures can demonstrate the level of the problem in the extremity but cannot determine the extent of stenosis or obstruction that is present. A drop in pressure between segments usually indicates disease, but further investigation is necessary to determine if a stenosis or an occlusion is causing the drop in pressure. Collateral vessels in the legs may falsely elevate pressures even during arterial obstruction. Ultrasound is necessary to determine the location and extent of the disease.
92
Most commonly the posterior tibial and dorsalis pedis arteries are used to obtain the pressure at the ankle. Which of the following describes the correct calculation of the ankle brachial index?
A. highest ankle pressure on each leg divided by the highest brachial pressure
B. lowest ankle pressure on each leg divided by the highest brachial pressure
C. highest brachial pressure divided by the highest ankle pressure on each ankle
D. highest right ankle pressure divided by the right brachial pressure and highest left ankle pressure divided by the left brachial pressure
A
| When calculating the ABI, the highest ankle pressure on each leg is divided by the highest brachial pressure.
93
```
Rest pain is associated with ankle pressures less than ________ and toe pressures less than _______ will be associated with a non-healing wound.
A. 100mmHg, 30mmHg
B. 70mmHg, 50mmHg
C. 50mmHg, 50mmHg
D. 50mmHg, 30mmHg
```
D
Rest pain is associated with ankle pressures less than 50mmHg and toe pressures less than 30mmHg will be associated with a non-healing wound.
94
```
The following pressure readings from a segmental pressure evaluation were obtained in a patient suffering from low back and thigh pain. What is the ABI for each leg?
Lt Ankle 106
Rt Ankle 98
Lt Arm 124
Rt Arm 134
A. Lt = 0.85, Rt = 0.73
B. Lt = 0.85, Rt = 0.79
C. Lt = 0.79, Rt = 0.73
D. Lt = 1.17, Rt = 1.36
```
C
Lt ABI = 106/134 = 0.79
Rt = 98/134 = 0.73; always use the highest brachial pressure for both ABI calculations.
95
The Adson maneuver is helpful in the diagnosis of what vascular disorder?
A. Raynaud syndrome
B. Venous insufficiency
C. Collateral formation with carotid occlusion
D. Thoracic outlet syndrome
D
The Adson maneuver is a patient position used to evaluate flow changes with thoracic outlet syndrome. Palpate the radial pulse on the affected side with the elbow fully extended. Have the patient rotate their head to the side being tested and extend the neck. Then abduct, extend, and laterally rotate the shoulder. From this position, have the patient take a deep breath and hold. Assess the pulse response. A positive test is a decrease in pulse vigor from the starting position to the final position.
96
```
In photoplethysmography, the sensor uses ________ to detect _________ changes.
A. light, blood volume
B. light, blood pressure
C. pressure cuff, blood pressure
D. thin mercury tubing, volume
```
A
The prefix photo- refers to light. Plethysmography is a method used to detect changes in blood volumes in the extremities.
97
The following pressures were obtained in a patient with left claudication. What are the ABI values for both legs?
Right: PTA 128mmHg, DPA 124mmHg, Calf 130mmHg, Thigh 140mmHg, Brachial 130mmHg
Left: PTA 98mmHg, DPA 122mmHg, Calf 126mmHg, Thigh 138mmHg, Brachial 126mmHg
A. RT 0.98, LT 0.77
B. RT 1.01, LT 0.96
C. RT 0.95, LT 0.75
D. RT 0.98, LT 0.94
D
Right: 128mmHg/130mmHg = 0.98
Left: 122mmHg/130mmHg = 0.94
98
When performing a segmental pressure exam on a patient with claudication, which of the following describes the response to exercise in a patient with pseudoclaudication?
A. ABI will most likely be 0.5-0.9
B. ABI will most likely be <0.5
C. Leg pain will not be associated with a drop in ankle pressure
D. Leg pain will be associated with a drop in ankle pressure
C
Pseudoclaudication has an orthopedic or neurogenic cause and is not cause by ischemia. The ABI will be normal and there will be no drop in ankle pressure with exercise.
99
A patient presents for a bilateral segmental pressure exam of the lower extremities. The chart lists a history of a bilateral mastectomy in 1980. How will this affect your exam?
A. a wrist pressure must be obtained instead of a brachial pressure and this number will be used to calculate the pressure indices
B. if the surgical procedure was performed more than 15 years ago, the exam should be completed using the standard protocol
C. the pressure indices cannot be calculated and the exam will be limited to waveform analysis only
D. the patient must be evaluated in the standing position for the pressure measurements
C
Brachial blood pressures are prohibited on the ipsilateral arm of a mastectomy patient. With the bilateral mastectomy, neither brachial pressure should be obtained. If you cannot perform a brachial pressure or both brachial pressures are abnormal, calculation of indices (ABI or TBI) would underestimate the disease. In these cases interpretation would need to be by waveform analysis only.
100
An ABI of 0.77 indicates ________ disease.
A. severe
B. minimal
C. unable to determine without exercise portion
D. mild - moderate
```
D
ABI criteria:
Minimal disease 0.9 - 1.0
Mild/Moderate disease 0.5 - 0.9
Severe disease <0.5
```
101
A patient presents for penile Doppler and segmental pressure exam due to impotence. The ABI is >1.0 bilaterally. The PBI is 0.8. What should be done next to evaluate this patient?
A. use papaverine to assess for increased venous outflow
B. write the results as normal with no explanation of impotence
C. have the patient perform 5 minutes of exercise on the treadmill at 12% grade
D. use papaverine to assess for decreased venous outflow
A
If the PBI is normal in the initial exam, papaverine can be injected at the base of the penis. If the PBI drops, vasculogenic impotence should be suspected. If venous outflow increases post-injection, this can be another cause of impotence in cases with normal arterial inflow.
102
```
Which of the following is a contraindication for a lower extremity segmental pressure exam?
A. current anticoagulant treatment
B. ulceration on the distal calf
C. ulceration on the 3rd and 4th toes
D. diabetes mellitus
```
B
Contraindications:
Suspected or known acute deep venous thrombosis - use waveform analysis only or use of a toe-brachial index (TBI)
Recent surgery, trauma site or ulcers that cannot/should not be compressed by pressure cuffs
Patients with incompressible arteries due to medial calcification - TBI may be used instead
Morbidly obese patients - high-thigh pressure may be unobtainable or inaccurate due to limb girth
Patients with significant tremors or involuntary movements that may cause waveforms to be suboptimal or unreliable
Ulcerations on the 3rd and 4th toes would not be compressed by cuffs. While diabetes mellitus can cause medial calcification which could inhibit the exam, not every patient with DM has medial calcification.
103
```
A _______ cuff is usually used to assess wrist pressure and a _______ cuff is usually used to assess digit pressure.
A. 10cm, 7cm
B. 12cm, 2.5cm
C. 2.5cm, 1cm
D. 7cm, 2.5cm
```
D
| A 7cm cuff is usually used to assess wrist pressure and a 2.5cm cuff is usually used to assess digit pressure.
104
You are evaluating a patient with suspected Raynaud disease using PPG. After obtaining a baseline tracing, you place the hand in cold water for 2 minutes. Once the hand is removed, PPG sensors are reapplied to the fingertips. Which of the following correctly describes normal results for this exam?
A. waveform amplitude increases to at least 2X the original
B. waveforms return to baseline within 7 minutes after removing the hand from the cold water
C. waveform amplitude increases to at least 4X the original
D. waveforms return to baseline within 5 minutes after removing the hand from the cold water
D
Cold sensitivity test is used to evaluate suspected Raynaud disease. A normal exam would demonstrate PPG tracings that return to baseline levels within 5 minutes after the hand is removed from the cold water.
105
A segmental pressure exam demonstrates the following pressures; right arm: 142mmHg; right leg: proximal thigh 140mmHg; distal thigh 126mmHg, calf 116mmHg, ankle 112mmHg. Which of the following could explain these results?
A. infrapopliteal disease
B. pelvic mass
C. pelvic mass or mid femoral artery stenosis
D. medial calcification
B
Using the four cuff method, the proximal thigh pressure should be 30-40mmHg higher than the brachial pressure. The pressures are decreased in the entire leg at small intervals from the thigh down. This indicates aortoiliac disease or possible intrinsic compression of the iliac artery by a pelvic mass.
106
```
What setting on the photoplethysmography system should remain constant during an extremity arterial evaluation and if it is adjusted it must be documented on the tracing?
A. size control
B. sweep speed
C. baseline level
D. signal output
```
A
The size control on the PPG system should be set at a constant level (10) and should not change during the exam. The PPG tracings demonstrate the amplitude of the reflected light, which indicates blood volume changes in the toe. The size setting should be kept constant to best demonstrate changes in blood volume between toes/feet. If the size control is adjusted, it must be documented on the affected tracings.
107
A segmental pressure exam is performed for a patient who is experiencing rest pain in the right leg. An ABI of 0.42 was found on the right leg. Which of the following statements is true regarding the findings?
A. exercise testing will provide additional diagnostic information for this patient
B. the patient will be referred to a vascular surgeon for intervention
C. a PVR exam will provide additional diagnostic information for this patient
D. a tourniquet will be applied to the upper thigh and the ankle pressure repeated
B
There is significant disease present. Exercise testing or a pulse volume recording exam will not provide additional information that will aid the physician in diagnosis and treatment. The patient is already a candidate for surgical intervention.
108
A patient presents with a script for an upper extremity PPG exam to rule out Raynaud syndrome. How will you perform the exam?
A. place the PPG sensors at the antecubital fossa and apply tourniquets at multiple levels on the arm to assess changes in flow
B. place PPG sensors on the wrist before and after cold sensitivity testing
C. Raynaud syndrome cannot be evaluated with PPG techniques
D. Place PPG sensors on the tips of the fingers before and after cold sensitivity testing
D
| PPG sensors are used to detect changes in flow in the finger tips during cold sensitivity testing for Raynaud syndrome.
109
Which of the following patients would undergo reactive hyperemia for a lower extremity exam to evaluate new onset of left leg claudication?
A. prior history of synthetic graft in the right leg
B. prior history of DVT 3 years ago
C. prior history of untreated multilevel disease in the right leg
D. prior history of coronary bypass surgery
C
Reactive hyperemia is the transient increase in blood flow that occurs after a brief period of ischemia. It commonly occurs following the removal of a tourniquet, unclamping an artery during surgery, or after vessel recanalization cause by a device or medication. Reactive Hyperemia Testing uses occlusive cuffs to simulate exercise in patients unable to perform treadmill testing. The procedure is used to simulate exercise for those patients unable to perform treadmill testing for arterial disease. If a patient has known disease in the right leg, the diseased leg may limit the treadmill exercise tolerance for the left leg. Reactive hyperemia testing will better evaluate the new symptoms in the left leg.
110
```
A diabetic patient presents with an injury to his big toe that won't seem to heal and has been open for over 3 weeks. Which of the following exam techniques should be used to evaluate this patient?
A. treadmill testing
B. segmental pressure exam
C. digital pressures and PPG evaluation
D. cold sensitivity testing
```
C
Digital pressures are more accurate in evaluating flow in the legs/feet than the ABI due to medial calcification of the calf/ankle vessels.
111
```
The following pressures were obtained at the levels listed: Lt PTA 110mmHg, Lt DPA 130mmHg, Lt Arm 150mmHg, Rt Arm 145mmHg, PTA 155mmHg, DPA 130mmHg. What is proper ABI calculation?
A. Lt 130/150; Rt 155/145
B. Lt 110/150; Rt 130/150
C. Lt 110/150; Rt 130/145
D. Lt 130/150; Rt 155/150
```
D
| The ABI is calculated with the highest ankle pressure divided by the highest arm pressure. Lt 130/150 and Rt 155/150.
112
A diabetic patient with a history of chronic renal failure and dialysis treatment presents with leg pain with walking. Which of the following is a potential complication for performing a segmental pressure exam on this patient?
A. the arm without the dialysis port is the only brachial pressure used in the evaluation
B. medial calcification may lead to overestimation of the ankle pressures
C. dialysis patients cannot be placed in the supine position for more than a few minutes, so the segmental exam will need to be performed with the patient seated in a chair
D. more than on of the above
D
The arm with the hemodialysis graft should never be used for taking system BP. Applying that much external pressure to the arm can cause graft failure. Diabetes can lead to medial calcification, which causes overestimation of the ankle pressures. Unless the patient has an additional health issue that prevents them from being supine for the exam, all patients having a segmental pressure exam should be evaluated in the supine position.
113
Why should a segmental pressure exam be performed with the patient supine?
A. to increase the pressure in the venous system and reduce the pressures in the arterial system
B. to provide the most comfortable position for the patient during the lengthy exam
C. to eliminate the influence of hydrostatic pressure on the brachial pressures
D. to eliminate the influence of hydrostatic pressure on the ankle pressures
D
Hydrostatic pressure can cause an overestimation of pressures in the ankles. Segmental pressure evaluations should be performed with the patient supine.
114
While performing an arterial Duplex exam, you obtain a triphasic waveform in the proximal femoral artery but the mid segment of the femoral artery and the rest of the leg arteries demonstrate a monophasic waveform. The brachial pressure is 140mmHg. Which of the following lists the correct expected pressures from the four cuff segmental exam on the same patient?
A. Upper Thigh 155mmHg, Distal Thigh 155mmHg, Popliteal 120mmHg, PTA 110mmHg
B. Upper Thigh 155mmHg, Distal Thigh 125mmHg, Popliteal 160mmHg, PTA 155mmHg
C. Upper Thigh 175mmHg, Distal Thigh 120mmHg, Popliteal 110mmHg, PTA 95mmHg
D. Upper Thigh 120mmHg, Distal Thigh 120mmHg, Popliteal 110mmHg, PTA 100mmHg
C
A drop in pressure >30mmHg between two adjacent segments indicates significant disease in the artery between the two cuffs. If there is a suspected mid SFA stenosis or occlusion, there will be a significant drop in pressure between the two thigh cuffs.
115
How should you prepare the patient to start the examination used to assess the venous refill time using photoplethysmography?
A. standing with the sensor at the medial malleolus
B. supine legs elevated with pressure cuff on thigh
C. supine legs elevated with sensor at the medial malleolus
D. seated at the edge of the table with lower legs dangling, sensor placed at medial malleolus
D
A PPG exam is used to calculate the venous refill time (VRT). A sensor is placed at the medial malleolus and the patient is seated at the edge of the table with their legs dangling. The patient performs a series of foot dorsiflexions to empty the blood from the calf. The strip chart recorder demonstrates the changes in blood volume over time. The time that it takes for the line to plateau again is the venous refill time. VRT >20 seconds is normal; <20seconds indicates insufficiency. If using APG to evaluate the VRT, a cuff is placed on the lower leg and the patient is put in the supine position with the affected leg elevates and the VRT is recorded as volume returns to maximum levels under the cuff.
116
A segmental pressure exam is performed with the following results. Lt arm 140mmHg, Lt ankle 155mmHg; Rt arm 110mmHg, Rt ankle 145mmHg; which of the following correctly describes the findings?
A. there is no vascular disease present in the right leg, but the left leg demonstrates mild disease
B. there is mild vascular disease present in the lower extremities
C. there is mild vascular disease present in the lower extremities and there is most likely a subclavian steal
D. there is no vascular disease present in the legs, but there is most likely a subclavian steal present
D
The ankle pressures are normal at a level higher than the highest pressure. The large difference (>20mmHg) between the brachial pressures is usually indicative of a subclavian steal.
117
Which of the following correctly describes cuff placement for a segmental pressure exam?
A. the proximal edge of the cuff should always cover a bony structure like the malleolus or tibial tubercle
B. once the patient is supine, ask him/her to raise their foot about 6 inches above the table so you can properly wrap the cuff around the leg
C. the width of the cuff should be at least 20% narrower than the girth of the limb segment
D. cuffs should be placed straight around the limb, rather than angled to the curve of the limb
D
The bladder of the cuff must be placed over the artery being evaluated and only compress soft tissue, not bony structures. The below-knee or upper calf cuff should be placed just distal to the tibial tubercle or pressure readings will be falsely elevated. The lower calf cuff should be placed with the distal edge 2-3cm above the medial malleolus. The width of the cuff should be at least 20% wider than the girth of the limb segment. The patient should rest the leg during cuff placement. Raising the leg causes muscle contraction and when released, the cuff will be too loose. Cuffs should be placed straight around the limb, rather than angled to the curve of the limb.
118
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Which of the following is not a characteristic of a normal PVR tracing of the lower extremity?
A. anacrotic limb
B. diastolic flow reversal
C. dicrotic notch
D. peaked amplitude
```
B
| PVR waveforms do not have a flow reversal component. The tracing represents volume which never goes into the negative.
119
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Abnormal results for a penile Doppler evaluation that suggest impotence include __________ peak systolic flow velocity and a peak pressure __________.
A. <25cm/s, <60mmHg
B. >60cm/s, >60mmHg
C. <60cm/s, >60mmHg
D. >30cm/s, >60mmHg
```
A
Abnormal results for a penile Doppler evaluation that suggest impotence include <25cm/s peak systolic flow velocity and a peak pressure <60mmHg.
120
An asymptomatic patient demonstrates a normal left ABI, but the left tibial arteries demonstrate a monophasic waveform with sharp upstroke and rapid deceleration. What is the most likely cause for this finding?
A. scale settings set too high to detect low velocity flow reversal
B. filter settings set too low to detect diastolic flow reversal
C. the patient should be evaluated for popliteal entrapment
D. Raynaud syndrome
A
The rapid acceleration and deceleration indicate a high resistance waveform that would be normal in the tibial arteries. The diastolic flow reversal component can be very small due to low velocity and a short duration of the flow. Decreased scale and filter settings will aid in visualization of this component of the waveform.
121
A 9 year old presents with chronic fatigue and decreased palpable femoral pulses. The ankle brachial index is performed with the following results. Lt arm 168mmHg, Lt ankle 95mmHg; Rt arm 174mmHg, Rt ankle 86mmHg; Which of the following is the most likely explanation of the findings?
A. there is most likely a coarctation of the descending aorta
B. there is most likely atherosclerosis vascular disease present in both lower extremities
C. there is most likely a subclavian steal present
D. the bilateral ABIs are normal
A
The arm pressures are significantly higher than normal. The leg pressures are lower than normal. The bilateral occurrence indicates an aortic abnormality.
122
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When a patient performs exercise on a treadmill what will be the normal change in the ankle brachial indices?
A. increased by more than 0.3
B. decreased by less than 0.3
C. unchanged or mild increase
D. unchanged or mild disease
```
C
The pressures in the ankles and arms may demonstrate a mild increase in pressure with exercise but the brachial and ankle pressure will increase together in a normal patient. This will lead to a consistent ABI calculation. A mild increase in the ABI may also be normal. A decrease in ankle pressure indicates an abnormal response.
123
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A diabetic patient presents for a segmental pressure exam. The calf and ankle vessels are non-compressible with up to 220mmHg. What alternative exam can be performed to evaluate lower extremity pressures?
A. photoplethysmography and toe cuffs
B. photoplethysmography with ankle cuffs
C. Doppler ultrasound
D. pulse volume recording exam
```
A
The tiny vessels of the toes are usually spared from medial calcification. PPG waveforms and pressure measurements can be taken of the toes when the ankle pressures are falsely elevated.
124
Venous PPG tracings are obtained. The right side demonstrates a venous refill time of 30 seconds. The left side demonstrates a refill time of 23 seconds. Which of the following describes the next step in evaluation?
A. a tourniquet will be applied to both legs at the thigh level and the VRT assessment will be repeated
B. a tourniquet will be applied to the left leg at the thigh level and the VRT assessment will be repeated
C. a tourniquet will be applied to the right leg at the thigh level and the VRT assessment will be repeated
D. the results are normal. No further evaluation is necessary.
D
| A normal VRT is greater than 20 seconds.
125
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A 25yr old presents with recent onset of left calf pain when riding his bike. He has been training for a race for the last six months without problem until 2 weeks ago. Exercise testing demonstrates a 50mmHg drop in pressure compared to the right leg with no drop in pressure. These findings are most suggestive of:
A. popliteal entrapment
B. Buerger disease
C. popliteal cyst
D. incorrect cuff placement
```
A
As the patient trained for the race, muscle built up in the calf over last six months to cause problems now. Popliteal entrapment is the most likely cause for the symptoms.
126
Which of the following describes the appearance of a significantly abnormal arterial PPG waveform?
A. low amplitude with prominent dicrotic notch
B. high amplitude with loss of the dicrotic notch
C. high amplitude with prominent of the dicrotic notch
D. low amplitude with loss of the dicrotic notch
D
The normal PPG waveform should be high amplitude with a dicrotic notch on the downslope. Loss of the notch and decreased amplitude indicate significantly abnormal flow.
