CARDIOVASCULAR EXTREMITY S +S
(Linda Costarella)
I. Peripheral Vascular Disorders
A. Arterial Disease
1. Acute occlusion
a. Causes
-embolism: solids(plague), gases(air), thrombus
-thrombosis usually affects a vessel that is athersclerotic
-trauma
b. Symptoms
-rapid 1-2 hours; pain, starts as numbness and tingling; coldness; numbness; pallor and
weakness
-most likely asymptomatic before
c. Signs
-temperature change in the extremity
-femoral artery occluded ; knee will be cool
-popliteal artery occluded: distal leg will be cool
-assymetric pulses; diminshed or absent
-pulse proximal to the occlusion will be bounding
-dorsalis pedis is variable in people; the posterior tibial more accurate
-pallor of the limb in the dependant position(weight bearing)
-decrease in sensation(soft touch, temp discrimination, sharp touch, etc)
-decreased muscle strength and digits may be difficult to move
d. Important History
-MI: arterial occlusion
-hx of rheumatic heart disease
-history of trauma
2. Chronic Occlusion
a. Causes
-athersclerosis is 90 % of cause
- secondary to diabetes
-Buerger's Disease(medium sized arteries)
-vasospastic disorders: Raynaud's phenemenon(idiopathic if primary dz) ; autoimmune,
connective tissue disorders
b. Symptoms
-pain(intermittent claudication); may have pain on rest; leg with chronic occlusion would
be red or violet usually with dependant movement;ulcerations(advanced) which could be
due to trauma or can occur with diabetes mellitus
c. Signs
-pulses diminished of absent, more likely to be bilateral (due to chronic being more
systemic)
-hair loss or diminshed hair growth
-may be able to hear bruits (abdom, popliteal or femoral)
d. Important History
-diabetes mellitus, hypertension, family history of strokes and heart disease, medications
that may be causing the vasospasm
B. Venous Disease
1. Superificial Phlebitis S+S
-usually painful; usually the course of the great saphenous veins; varicosities can also be
painful; usually no systemic sx ; vein may feel like cord; may be nodules along cord
-significant negative is normal arterial pulses
2. Acute Deep Phlebitiis
a. Causes
-trauma, stagnation of blood flow(elderly, dehabiliated), coagualation; trauma to leg(femur
and calf)->can lead to embolus
b. S+S
-sudden onset of edema(acute); aching pain but not related to exercise; relieved by
elevation; bluish modelling of skin in dependant position; malaise without chills;
tenderness over affected deep veins; superficial veins dilated with increased work load;
-DDX:ruptures of tendon of plantaris and gastrocs tendon; infection
3. Chronic Deep Phlebitis S+S
-edema with standing; skin thick and tougher and a little discolored; dermatitis
Risks factors for Deep vein Thrombosis
-post operative, post partum, prolonged bed rest, prolonged travel with legs in dependant position,
heart failure and stroke(creates stasis), hypercoagulation from malignant tumor , oral
contraceptives
II. Discussion of Individual sign & symptoms
A. Pain
-causes of pain in lower extremity: strains of muscles, sprains in ligaments; degenerative joint disease,
sciatica, gout, intermittent claudication, phlebitis, and varicosities; therefore, history is extremely important
1. Important attributes
-location, quality of pain(aching, sharp), age, pain related to exertion
-pregnant women: venous insufficiency, thrombus phlebitis , muscle pain
-elderly: NB to look at cardiovascular, gout
2. Intermittent Claudication
-most commonly seen in calf; pain with movement; no symptoms at rest; pain can manifest as
fatigue, achiness; distance pt. can walk is less than normal(set distance and set time of rest for
relief); relief will occur if they stop moving but could still be weight bearing
a. causes
-uncommon in people under 50; most commonly seen in legs; history of diabetes mellitus,
hypertension; hyperlipidemia, or tobacco use
-femoral or popliteal artery: the calf or the foot will be the common area ofpain
-aorta or iliac artery: pain in thigh and buttocks
-progresses to continual pain
-history and PE findings are: distance they can walk, how long to rest, has this changed,
risk factors for athersclerosis, pedal pulses, bruits(check all), compare the limbs for color,
size, temperature, elevate the leg for 2 minute and see if it turns white and hang it back
down and see how long it takes to get color back; deep tendon reflexes after exercise
are diminished
b. Comparison with non-cardiovascular claudication
-vascular claudication: clamping
-neurological claudication: numbness and burning; not changed by rest or movement
B. Color Changes
1.Cyanosis
-bluish or bluish /black; discoloration of mucus membranes and skin
-excess unoxygenated hemoglobin
-described as : abrupt(vascular occlusion, excess vasocontriction) or gradual, central (sluggish
circulation by decreased cardiac output commonly from heart failure) or peripheral (can be
widespread or local)
DDX:
-transient cyanosis from environment ie. cold, decreased oxygen pressure(altitude, asthma, and
COPD)
-chronic atherosclerosis: also have weakened or absent pulse and intermittent claudication
-heart failure: abrupt or gradual; tachycardia
left heart failure:more central than right sided heart failure, edema, dyspnea on exertion,
paradoxial noctural dyspnea, gallop or rales in the base of lungs, othopnea
right heart failure: jugovenous distention, peripheral cyanosis, hepatomegaly, ascites
-Buerger's Disease : cyanosis with exposure to cold, feet cold and numb, intermitten claudication
of instep, weak peripheral pulses, late stage : ulcers
-deep venous thrombosis: periphaeral cyanosis in effected limb, tenderness, edema, prominent
superifcial veins, warmth, positive Homan's sign
-Raynaud's: similar to Buergur's dz(smokers)
2. Erythema
-may see in thrombophlebitis
-white cold numb cyanotic limb which becomes red and tingling is seen in both Bueger's and
Raynaud's
3. Pallor
-seen in acute or chronic arterial occlusion, Raynaud's (abruptly pale and cyanotic and with
warmth becomes red with abnormal sensations & parastesia)
4. Capillary Refill
-press on finger nail and see how quickly it comes back after releasing
-normal should <3 seconds, prolonged refill: arterial occlusion ie.aortic bifurcation(late sign),
Buergers' and Raynaud's
5. Mottled Skin
-acute arterial occlusion; may see in Buerger's disease
C.Pulses
-0-4+ system
-absent or weak pulses inmost things talked about specifcally the vascular occlusion diseases.
D. Bruits
-caused by turbulence(narrowing of lumen or weakened wall); aneurysm
E. Edema
-venous disorders (with out hair loss and intermittent claudication)
F. Muscle Spasms
-arterial occlusion disease (hair loss and edema)
G. Homan's sign
-deep vein thrombosis will have a positive sign in 35 % of px; positive sign could also be due to calf
muscoskeletal pain, achilles tendon strain , or arterial occlusion
-DDX: cellucitis, superficial thrombosis with negative Homan's sign