lecture 15 valentine
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| the 6 Ps of acute arterial insufficiency | pain, pallor, poikilothermia, pulselessness (does not progress to final two sx if there's collateral flow; otherwise:) paresthesia and finally paralysis
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| paresthesia and paralysis in context of acute arterial insufficiency suggest? | there is an imminent irreversible neurological damage; critical window is 4-6 hrs to be able to save limb
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| intermittent claudication | suggests mild-moderate arterial insufficiency, causes reversible functional disability of a limb, dull ache precipitated usually within buttock, thigh, leg, calf or foot muscles while walking is relieved by resting, non-limb threatening and reproducible
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| what are the 2 clinical presentations of chronic arterial insufficiency? | intermittent claudication and ischemic rest pain
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| ischemic rest pain | suggests severe, advanced arterial insufficiency, causes continuous ache and paresthetic discomfort in forefoot (ball of foot) and distally in toes, aggravated by elevating/ameliorated by lowering it, may progress to gangrene and require amputation
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| pathophysiology of intermittent claudication | blood flow is adequate to meet muscle's metabolic needs until pt begins walking and can't inc flow due to occlusive dz; therefore, anaerobic glycolysis begins and lactic acid builds up = pain
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| when is calf claudication predominantly seen? | in cases of most commonly occluded peripheral artery - superficial femoral OR in diabetics with distal arterial occlusive dz (may also see foot claudication in these pts)
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| pathophysiology of ischemic rest pain | severe arterial occlusive dz causes nerve ischemia; gravity works to inc blood flow and venous pressure somewhat, which prolongs period that RBCs stay in capillaries and maximizes oxygen exchange times
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| how to differentiate btwn ischemic rest pain and diabetic peripheral neuropathy | both cause numbness however ONLY ischemic rest pain is typically unilateral, worsened with elevation and made better by lowering ext. diabetic neuropathy is bilat, most intense on soles of feet (stocking distribution) and doesn't change with positioning
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| why gout, metatarsalgia, osteoarthritis and trauma are NOT same as ischemic rest pain | gout: elevated urate levels and inflammation // metatarsalgia: pain with joint ROM // osteoarthritis: pain in joint (not muscle) and persists independent of positioning // trauma: HPI, pain with squeezing
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| The 5-year risk of major amputation for a patient with claudication is: | 5%
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| dimensions of vessel that qualify an aneurysm | vessel size is 1.5x the diameter of its counterpart on opposing side (aorta in a nl male is 2 cm in diameter)
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| easiest way to find femoral pulse even in a morbidly obese person | palpate the anterior superior iliac spine and the pubic tubercle, femoral artery should be halfway btwn the 2 landmarks
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| easiest way to find dorsalis pedis pulse | just lateral to the extensor hallucis longus tendon on dorsal surface of foot
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| AAA rupture triad, emergent vascular surg case | PAIN in back, flank or abd // PULSATILE MASS // SHOCK
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| risk of rupture > operative risk when AAA diameter exceeds 5.0-5.5 cm |
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| describe the best way to examine for AAA | ~ 95% of AAAs are infrarenal, thus palpating just at level of or above the umbilicus is best. if pt is obese, palpate halfway btwn the iliac crests. pt must be relaxed, feel from lateral to midline
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| TIAs | episodes of focal loss of brain function due to ischemia, usually from carotid or vertebral a. pathology, commonly last 2-15 min, no evidence of cerebral infarction on CT/MRI, dx'ed by HPI/sx/exam
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| signs of R carotid TIA | L body motor and sensory deficit, upper body usually most affected. aphasia will occur usually only when the R hemisphere is dominant for speech (thus L handed)
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| signs of L carotid TIA | R body motor and sensory deficit like dysarthria or expressive aphasia, weakness, clumsiness, loss of vision in the L eye, paresthesias, etc.
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| signs of vertebral-basilar TIA | BILATERAL motor and sensory, diplopia, cerebellar sx like dysequilibrium
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| amaurosis fugax | "without sight fleetingly" - monocular blindness during retinal artery flow interruption on ipsilaterally affected side (TIA); "curtain shade" descending or ascending over half of the visual field
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| pathophysiology of TIAs or stroke | atheroembolism stemming from carotid bifurcation, plt-fibrin emboli, carotid thrombosis, severe stenosi that greatly reduces flow causes distal ischemia
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| presence of carotid bruit is only loosely correlated with carotid stenosis | 1:3 pts with bruit will have ICA stenosis
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| which type of aortic dissection requires emergency intervention? | Stanford type A. // Stanford type B is treated medically
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| risk of recurring sx within 2 yrs in pt with carotid stenosis that's moderate-severe | 26% risk of recurrence of some type of thromboembolic event (TIA, CVA, etc)
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