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Flashcards in PV Deck (84):
1

Injury to vascular endothelial cells provokes...

thrombus formation, atheromas (fatty layers), and vascular lesions of HTN

2

atheroma, pathogenesis

  • begins in intima (inner layer of vessels) as lipid-filled foam cells and then becomes fatty streaks. 
  • Complex atheromas are thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken underlying media
    • They have soft lipid core and fibrous cap of smooth muscle cells and collagen-riich matrix
  • Plaque rupture may precede thrombosis

3

location of brachial artery

bend of elbow just medial to biceps tendon

4

location of radial artery

lateral flexor surface of forearm

5

location ulnar artery

medial flexor surface of forearm

overlying tissues may obscure ulnar artery

6

location femoral artery

just below inguinal ligament, midway between ASIS and symphysis pubis

7

location popliteal artery

extension of femoral artery that passes medially behind femur, palpable just behind knee

DIvides into dorsalis pedis and posterior tibial

8

location dorsalis pedis artery

dorsum of foot just lateral to extensor tendon of big toe

9

ocation posterior tibial artery

behind medial malleolus of ankle. 

An interconnecting arch between its two chief arterial branches protects circulation to the foot

10

layers of arteries

3 concentric: intima, media, adventitia

11

Where do the veins of the arms, upper trunk, head and neck drain? 

SVC, which empties into the right atrium

12

where do veins of legs and lower trunk drain?

upward into IVC

 

13

Important characteristic of leg veins

weaker wall structure, susceptible to irregular dilation, compression, ulceration, invasion by tumors = warrant special attn

14

intermittent claudication

symptomatic limb ischemia w/exertion

Present in atherosclerotic PAD

15

neurogenic claudication

pain w/walking or prolonged standing, radiating from spinal area into buttocks, thighs, lower legs, or feet

increases likelihood of spinal stenosis if pain is relieved by sitting or bending forward or if bilateral buttock or leg pain is present

16

PAD symptom location and site of arterial ischemia: buttock, hip

aortoiliac

17

PAD symptom location and site of arterial ischemia: erectile dysfunction

iliac-pudendal

18

PAD symptom location and site of arterial ischemia: thigh

common femoral or aortoiliac

19

PAD symptom location and site of arterial ischemia: upper calf

superficial femoral

20

PAD symptom location and site of arterial ischemia: lower calf

popliteal

21

PAD symptom location and site of arterial ischemia: foot

tibial or peroneal

22

abdominal pain, "food fear", and weight loss suggest ...

intestinal ischemia of the celiac or superior or inferior mesenteric arteries

23

ABI

ankle divided by brachial BP

  • >0.9 = normal
  • <0.89 - > 0.60 = mild PAD
  • <0.59 to >0.40 = moderate PAD
  • <0.39 = severe PAD

24

Key components of Peripheral Arterial Exam

  • BP in both arms
  • Carotids: palpate, auscultate
  • Auscultate aortic, renal, femoral 
  • Palpate aorta & determine diameter
  • Palpate brachila, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial arteries
  • Inspect ankles & feet for color, temperature, skin integrity; not ulcerations, hair loss, trophic skin changes, hyper trophic nails

25

Prominent veins and edematous arm suggest...

venous obstruction

26

Grading of pulses

  • 3+ bounding
  • 2+ brisk, expected (normal)
  • 1+ diminished, weaker than expected
  • 0 absent, unable to palpate

27

warmth and redness over calf signal 

cellulitis

28

atherosclerosis most commonly obstructs arterial circulation to...

the thigh. Normal femoral w/diminished to absent popliteal

29

Calf asymmetry, Differential Dx

  • DVT
  • muscle tear or trauma
  • Baker's cyst (posterior knee)
  • muscular atrophy

30

Characteristic of venous cause to edema

venous distention - bilateral present in heart failure, cirrhosis, nephrotic syndrome

31

ulcer location: arterial, venous

arterial: often anterior tibiae, dry or brown-black from gangrene

venous: brownish discoloration or ulcers just above malleolus

32

dependent rubor

suggests arterial insufficiency, but not reliable if veins are incompetent 

33

Mapping varicose veins

patient standing. placepalpating fingers gently on vein. compress w/bottom hand - feel for wave in upper hand

 

34

Evaluating competency of venous valves

Retrograde filling (trendelenburg) test

  • pt supine.
  • elevate one leg to about 90 degrees to empty it of venous blood.
  • occlude great saphenous vein in upper thigh by manual compression, using enough pressure to occlude this vein but not deeper vessels.
  • Ask pt to stand while you keep vein occluded.
  • Watch for refilling of leg. Should refill from below, takes about 35 seconds
  • After 20 seconds of standing, release compression and look for sudden additional venous filling - normally there is none - competent saphenous valves should obstruct retrograde flow
  • both steps normal? negative-negative

difficult w/older - may want doppler study instead​

 

35

lymphedema

soft in early stages, then indurated, nonpitting. 

skin markedly thickened, ulceration rare, no pigmentation

d/t lymph channels blocked by tumor, fibrosis, inflammation

36

Allen Test

  • Ask pt to make tight fist w/one hand, then compress both radial and ulnar arteries firmly between your thumbs and fingers
  • Ask pt to open the hand into a relaxed, slightly flexed position. Palm is pale
  • Release pressure over ulnar artery, if patent, palm flushes w/in 3-5 seconds 

important b/c collateral arches must be patent

37

Cap Refill

 

  • Blanch the beds and release
  • Normal capillary refill time is within 3 second
  • >5 seconds indicates arterial vascular insufficiency
     

38

VTE

venous thromboembolism

an umbrella term classifying PEs (1/3) and DVTs (2/3)

39


Vascular Arches
 

-connect the radial and ulnar arteries protecting the distal circulation in the hand from arterial occlusion

40

Veins in the Legs

A image thumb
41

Rubor indicative of  

arterial disease - ruddy color

42

Great saphenous vein


originates on the dorsum of the foot passing anterior to the medial malleolusèup the medial aspect of the leg joining the femoral vein of the deep venous system below the inguinal ligament
 

43

Small Saphenous Vein


begins at side of footètravels upward along the posterior calf joining the deep venous system in the popliteal fossa
 

44


What does the loss of a femoral pulse represent?
adult/gero vs pedi

  • adult/gero: is it acute or chronic? may be increase in insufficiency, look for intermittent claudication, trophic changes in skin, postural color changes. 
  • Pedi: coarctation of the aorta, congenital abnormalities in arterial blood flow, diastolic HTN

45

Coarctation of the Aorta

  • congenital narrowing of aorta, causes severe obstruction. Most often picked up in first days, but can be later in life. Branches must be perfused by collateral blood flow
  • common in Turner syndrome, some birth defects, may also have VSD
  • Clinically: femoral pulse is weak or absent. BP is weaker in legs than arms, possibly w/HTN

A image thumb
46

Arterial vs venous insufficiency

A image thumb
47

warmth over vein may be... 

thrombophlebitis

may have read streak, may have low-grade fever...

48

Dependent rubor and cyanosis of the 1st digit are characteristic of 

arterial insufficiency 

A image thumb
49

5 Ps of arterial occlusion

  • Pain
  • Pallor
  • Poikilothermia  (coolness)
  • Pulselessness
  • Paresthesia
  • Paralysis

Pain often involves the foot
Sudden onset

 

50

Raynaud’s Phenomenon

 

  • Episodic spasm of the small arterioles
  • Effects one or more fingers/toes
  • Numbness and tingling +
  • Pain may be present
  • Trigger-emotions, exposure to cold
  • Color changes to distal fingers, blanching --> cyanosis --> redness (as fills up again)
  • Warm climate (will move b/c so bad); Ca+ blockers (can help if very bad)
    Suggest: hands under warm water

A image thumb
51

pregnancy and thrombosis 

hormones, etc., can predispose

52

Venous Stasis vs venous insufficiency

Stasis:

  • Pigmentation
  • Dermatitis
  • Ulceration
  • Thrombus formation
  • Cellulitis

Insufficiency: obstruction in forward movement - can cause clots, varicose veins. Dusky brown, ulcerations

53


Superficial Thrombophlebitis
 

-acute episode of clot with local redness, tenderness and swelling with a palpable cord of superficial vein, most often sapehnous; may be febrile

54


Deep Venous Thrombosis
 

-clot in a deep vein; unilateral; tense muscle; may NOT have pain; aggravated by walking; relieved with elevation; may have swelling of calf and foot; previous hx of DVT-high risk factor

55


Chronic Venous Insufficiency
 

-chronic venous engorgement secondary to venous occlusion or incompetent venous valves; aching along let; chronic, worsening as day wears on; aggravating by prolonged standing; relieved with elevation; chronic edema, pigmentation, may have ulcers

56

Concerns associated with the PV System

  • Arteries, veins, or lymphatics
    • Occlusion
    • Atherosclerosis
    • Aneurysm
    • Valvular insufficiency
    • Infection
    • Malignancy

57

Meds common to those w/PVD

  • Insulin
  • Antiglycemics
  • Diuretics
  • Antihypertensives
  • Lipid Therapy
  • Oral Contraceptive Pills (OCP)/HRT
  • Anticoagulation
  • NSAIDs
  • Complementary/Alternative Therapy

58

The Lymphatic System: components

 

  • Lymph nodes
  • Tonsils and adenoids
  • Thymus gland
  • Spleen
  • Intestines known as Peyer’s patches

Lymph tissue

  • Bone marrow
  • Stomach mucosa
  • Appendix
  • Lungs

59

Most common cause of chronic arterial occlusive dz of lower extremities

  • chronic arterial insufficiency. Caused by arterial narrowing or obstruction, reducing blood flow. Leads to intermittent claudication, usually in calf. 
  • ABI usually <0.9
  • Treat w/aspirin, w/exercise therapy. More severe - angioplasty, stenting, surgical grafts...

60

Lymphatic movement


Peripherally-lymphatic capillaries --> centrally, thin vascular channels --> collecting ducts --> major neck veins
 

61

Role of lymph nodes


Aid in maturation of lymphocytes and monocytes, using phagocytosis and filtration
 

62

varicosities on back of calves/lower legs 

if on feet a lot, age

PVD

63

Lymphocytes

 

  • Found in bone marrow, lymph nodes, spleen, tonsils, adenoids
  • B-lymphocytes: bone marrow
  • T-lymphocytes: thymus 
     

64

Lymph nodes of lower extremities

Heel and outer aspect of the foot drain into the lesser saphenous vein to the deep popliteal space

A image thumb
65

Pitting Edema

 

  • Press firmly x at least 2 seconds
  • Check dorsum
  • Check medial malleolus
  • Shins
  • Grade (1-4+pitting)-slight to very marked
  • Unilateral or bilateral?
  • Measure circumference; note extension
  • Prominent veins?
  • Color/ulcers/thickness?
     

A image thumb
66

preauricular nodes

Eye, middle ear and parotids

67

postauricular nodes

Both inner & outer ear

68

occipital nodes

scalp, outer ear

69

Tonsillar nodes

Tonsillar and posterior pharyngeal regions. Also includes the mouth, larynx, thyroid, & trachea

70

submandibular nodes

mouth-mucosa, floor of mouth, face, nose, maxillary sinus

71

Submental nodes

Anterior portion of the mouth and lower lip, and teeth

72

Anterior cervical nodes

Internal structures of the throat, posterior pharynx, tonsils. Also the mouth, tongue, thyroid, trachea

73

posterior cervical  nodes

Mono/ other viral illness or respiratory infections

74

Infraclavicular nodes

Upper limb

75

Supraclavicular nodes

  • (Think malignancy)
  •    Right: Esophagus, Mediastinum, lungs, GI
  •    Left: Virchow’s node – Thorax, abdomen, lymphoma, thoracic or retroperitoneal cancer,  bacterial/fungal infection

76

axillary nodes

central, subscapular/posterior, anterior/pectoral, brachial/lateral

Infection of the upper extremity, chest wall, breast tissue of affected side, intrathoracic lesions, neck

77

epitrochlear nodes

Malignancy (non-hodgkin's lymphoma), infection of 3, 4,& 5  digits

78

Superior superficial inguinal nodes (horizontal) 

rectum, anus, genitals, buttocks, and abd wall below umbilicus.

79

Inferior superficial inguinal

(vertical-drains Leg)

80

visual for documenting pulses

A image thumb
81

What if you can't palpate the dorsalis pedis? 

ask them to flex their big toe toward ceiling - shows extensor tendon & you can palpate lateral to extensor tendon

82

characteristics of lymph nodes

soft, nontender, mobile

83

Shotty nodes

spray of lymph nodes in one area - d/t viral illness, etc. Should go away, if not, concerning

84

2 areas w/no lymphatic system

placenta & brain