Physiological PT I PDF

PHYSIOLOGICAL PT PHYSIOLOGICAL PT I| PERFORM DIGITAL PERFORM DIGITAL PRESSURES PRESSURES ONON ATLEAST...

PHYSIOLOGICAL PT PHYSIOLOGICAL PT I| PERFORM DIGITAL PERFORM DIGITAL PRESSURES PRESSURES ONON ATLEAST ATLEAST 1. An upper extremity segmental pressure ONE MORE ONE MORE DIGIT DIGIT ON ON THE LEFT THE LEFT exam produces the following pressures: ONE MORE ONE MORE DIGIT DIGIT ON ON THE LEFT HAND THE LEFT HAND HAND HAND © Brachial RT 140mmHg AND LT 132mmHg e when the arm pressures are normal © Radial RT 144mmHg AND LT e but the digital pressure is abnormally 136mmHg reduced o Ulnar RT 138mmHg AND LT e there could be disease in the palmar acrch 138mmHg or the single digit © 2nd Digit RT 130mmHg AND LT e to provide complete evaluation 104mmHg atleast one more digit on the left hand What should you do next for this patient? 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 e if the additional digit pressure is normal e the remaining digits should be tested to confirm that the reduced pressure is limited to the e single digit and disease of that digital artery should be suspected  The Adson maneuver The Adson maneuver isis helpful helpful in in the diagnosis the diagnosis B. THORACIC OUTLET SYNDROME of what of what vascular vascular disorder? disorder? e the adson maneuver ¢ is a patient position to evaluate flow changes with e thoracic outlet syndrome ¢ palpate the radial pulse on the affected side with elbow fully extended e have the pt rotate their head to the side being tested e and extend the neck e then abduct, extend, laterally rotate the shoulder e from this position e have the pt take a deep breath and hold e assess the pulse response © a postive test is a decrease in pulse vigro from the starting position to the final position B. 7 CM, 2.5 CM 3.A cuff is usually used to assess wrist Measurement Cuff Size pressure and a cuff is usually used to Wrist pressure assessment 7 om cuff assess digit pressure. Digit pressure assessment 2.5 cm cuff e 7 cm cuff is usually used to assess wrist pressure 0 2.5 cm cuff is usuaally used to assess digit pressure SEGMENTAL What is What is the most accurate the most accurate method method of of thigh thigh pressure assessment? pressure assessment? D. 3 CUFF SEGMETAL PRESSURE EXAM e 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 e smaller cuffs tend to overestimate the thigh pressure e the larger cuff used in the 3 cuff method provides a more accurate pressure. Which of the following is NOT an appropriate B. patient complains that the treadmill is too noisy reason to terminate the treadmill exercise for a lower extremity arterial exam? e anytime the pt reports symptoms of pain in the legs or the chest © the exam should be terminated © never try to talk the pt into continuing the exam © always record the duration of the exercise © location of the symptoms and changes in ankle pressures A diabetic patient with a history of chronic renal D. MORE THAN ONE OF THE ABOVE failure and dialysis treatment presents with leg pain with walking. Which of the following is a potential e the arm with the hemodialysis graft should complication for performing a segmental pressure never be used exam on this patient? e for taking BP ° applying that much external pressure A: The arm without the dialysis port is the only brachial pressure used in the evaluation. © to arm can cause graft failure B: Medial calcification may lead to overestimation e diabetes can lead to medial calcification of the ankle pressures. o which causes overestimation of the C: Dialysis patients cannot be placed in the supine ankle pressures position for more than a few minutes, so the o unless the patient has an additional segmental exam will need to be performed with the health issues patient seated in a chair. © that prevents them from being supine D: More than one of the above for the exam When performing a segmental pressure exam on a A. LEG PAIN WILL NOT BE ASSOCIATED WITH patient with claudication, A DROP IN ANKLE PRESSURE which of the following describes the response to exercise in a patient with pseudoclaudication? e pseudoclaudication has an orthopedic or neurogenic cause and is not caused by ischemia © the ABI will be normal © and there will be no drop in ankle pressure with exercise  Response to Ankle Ankle-Brachial Condition Exercise Cause Pressure Index (ABI) Claudication Leg pain due to Reduced blood flow Drop in Typically lower inadequate blood ankle due to ischemia flow (ischemia) pressure Pseudoclaudication —_No drop in ankle Orthopedic or No drop in Remains normal pressure with neurogenic cause (e.g., ankle despite exercise- exercise nerve compression, pressure induced spinal stenosis) symptoms A segmental pressure exam demonstrates the B: Pelvic mass following pressures: right arm: 142 mmHg; right leg: proximal thigh 140 mmHg, distal thigh 126 e using the four cuff mehod the proximal thigh mmHg, calf 116 mmHg, ankle 112 mmHg. Which of pressure should be 30-40 mmHg higher than the following could explain these results? the brachial pressure right arm : 142 mmhg e the pressures are decreased in the entire leg © at small intervals from the thigh down right leg: e this indicates aortoiliac disease or proximal thigh: 140 mmHg © possible intrinsic compression of the DISTAL THIGH: 126 mmHg iliac artery by a pelvic mass CALF : 116mmHg ANKLE : 112 mmHg 11. characterisitc of normal arterial PPG A. PROMINENT DICROTIC NOTCH waveform e AN ABNORMAL PPG WAVEFORM © dicrotic notch slow upslope oO ° slow downslope © little difference btwn systolic diastolic blood volumes fe) Catacrotic Anacrotic Limb _7~ Limb 1. An ABI of 0.77 indicates disease. D. MILD- MODERATE: 0.5-0.9 ABI Criteria Range Minimal Disease 0.9 - 1.0 Mild/Moderate Disease 0.5 - 0.9 Severe Disease < 0.5 You are preparing for a lower extremity segmental C. Obtain doppler waveforms and to brachial pressure exam on a patient with leg pain. indices She was admitted to the hospital 2 days ago due to extensive lower extremity DVT. e if patient has suspected or known acute How will you proceed? deep venous thrombosis © use waveform analysis only and/or use tow/brachial indices (TBI) o 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 foes not provide thrombolytic therapy » the DVT found 2 days ago = cannot have recanalized in such a short period of time = sonographer should never cancel an exam without referring physician approval  15. H/O B. Medial calcification HTN, DM , CORONARY ARTERY DISEASE ¢ medial calcification does not always cause ¢ a patient with history of HTN, DM and e an excessive ABI measurement of greater coronary artery disease complains of than 1.30 e bilateral rest pain relieved by dangling legs e the symptoms of significant ischemia do not over the edge of the bed e the 4th and 5th toe on the left foot have fit the normal ABI measurements blackened tips e the diabetic history also adds to the risk for e bilateral thickened toenails the medial calcification e very dry skin and hair loss are also noted on e toe pressures and/or PPG or PVR physical exam © evaluation will provide better the right ankle pressure: 148 mmHg information on this patient left ankle pressure : 144 mmHg highest arm pressure : 140 mmHg which statement is true regarding these findings? The 12cm blood pressure cuffs are missing from D: Brachial pressure, calf pressure, and ankle the lab. You perform the 3 cuff method lower pressure extremity segmental pressure exam with the 10cm cuffs on a patient that is 5'5" 150lbs. What Cuff Size Usage Effect of Using Smaller Cuff information that you will report will be invalid? 12cm Cuff Normally used for the thigh Pressure will be overestimated in the thigh 10cm Cuff Not typically used for the thigh Not suitable for accurate thigh pressure measurement A normal lower extremity arterial response to C. 1.0 Normal 0.9 - 1.0 Asymptomatic/minimal disease 0.5 - 0.9 Claudication/mild to moderate disease 1.30 Medial calcification causing abnormal increase in ankle pressure and ABI value ABI Value Strandness Criteria ABI > 0.5 Single vessel disease ABI < 0.5 Multiple vessel disease Condition Association Ankle pressures < 80 mmHg Associated with non-healing wounds Diagnostic Parameter Normal Range/Criteria Ankle Brachial Index (ABI) 0.9 - 1.3 Thigh Pressure 30-40 mmHg greater than brachial pressure; Thigh/ Brachial index > 1.2 Pressure in Adjacent Segments < 30 mmHg difference Pressure in Same Segment in Both Legs < 20 mmHg difference Toe/Brachial Index > 08 PSV (Peak Systolic Velocity) Change Between Less than a 2x increase Adjacent Segments Exercise Evaluation 5 min or more of walking without symptoms Increased peripheral resistance will lead to A) increased amplitude in PVR tracings. e increased peripheral resistance will lead to increased e amplitude in PVR tracings. e proximal disease will lead to a reduced amplitude © and loss of the dicortic notch Which of the following disorders would A. SVC SYNDROME demonstrate normal digital pressures in the upper extremity? e raynaud disease, TOS, buerger disease and atherosclerosis can all lead e to abnormally low digit pressures e and abnormal PPG tracing e SVC syndrome refers to © progressive thrombosis of the SVC e that is usually related to ° adjacent malignat tumor formation Which of the following patients would undergo B) Prior history of untreated multilevel disease in reactive hyperemia for a lower extremity exam the right leg to evaluate new onset of left leg claudication? e reactive hyperemia is the transient increase in blood flow that occurs after a brief peroid of ischemia e itis commonly occurs following the removal of a tourniquet e unclamping an artery during surgery ¢ or after vessel reccanalization caused by a device or medication reactive hyperemia testing uses: e occlusive cuffs to simulate exercise in pts e unable to perform treadmill testing e the procedure is used to stimulate exercise in pts unable to perform treadmill testing e the procedure is ued to stimulate exercise for those patients ubanle to perform treadmill testing for arterial disease e if a patient has known disease in the right leg e the diseased leg may limit the treadmill exercise tolerance for the left leg e reactive hyperemia testing will better evaluate the new symptoms in the left leg 71. A segmental pressure exam is performed with the D. there is no vascular disease present in the following results: legs, but there is most likely a subcvlavian steal Left arm: 140 mmHg present Left ankle: 155 mmHg Right arm: 110 mmHg Right ankle: 145 mmHg Which of the following correctly describes the findings? When performing post-occlusive reactive B) Immediately after cuff release and every 30 hyperemia, pressure measurements in the seconds until pressures return to baseline levels lower extremities are obtained: e when performing post occlusive reactive hyperemia of the lower extremities ¢ pressure measurements are obtained immediately after cuff release and every 30 seconds e until pressures return to baseline levels e recovery time is shorter for reactive hyperemia than treadmill testing When performing an upper extremity segmental B. RADIAL ARTERY DISEASE pressure exam, you obtain the following reading on the right arm. Right upper arm 140 mmHg, Right e 30 mmhg drop in the pressure btwn the radial artery 110 mmHg, Right ulnar artery 130 upper arm mmHg. Which of the following correctly explains the findings? e radial artery at the forearm © this indicates radial arterial disease e the ulnar artery pressure is only mildly decreased e does not indicate disease e a brachial obstruction would affect the pressure in both of the forearm arteries If the systolic brachial pressure is 116 mmHg, the D) 70 mmHg toe pressure would be considered normal if it is or greater. e the normal pressure in the lower extremity digits is normally at least 60% of the brachial pressure e 116 x.60 = 70 mmHG e the toe pressure is considered normal if it is 70 mmHg or higher Which of the following could cause a false C. USING THE 12 CM false elevation of the ankle reduction in ankle pressure on an average- pressure sized patient? © medial calcification © cuff too loose © cuff too small © patient not supine (hydrostatic pressure) e false reduction in the ankle pressure= © cuff too large © congestive heart failure © coarctation 76. A patient presents for an exercise arterial exam B) Extensive collateral formation after an abnormal resting exam. The report from the resting exam describes: elevated velocities that e excerise induces peripheral vasodilation indicate a stenosis of >50% in the distal femoral e if collateral flow is present artery on the left leg, biphasic waveforms in the PTA (Posterior Tibial Artery) and DPA (Dorsalis e it will compensate for the expected drop in Pedis Artery), and an ABI (Ankle-Brachial Index) of the flow 0.96. There is no change in the waveforms or e pressure from a diseased vessel decrease in ankle pressures in the left leg with exercise. What could explain these findings?  Explanation:The correct answer is D. Question:In a patient undergoing duplex ultrasound examination for peripheral arterial Persistence of normal waveform patterns distal disease, which finding is most indicative of to significant stenoses. extensive collateral formation? e Extensive collateral formation can provide alternative routes for blood flow, bypassing areas of stenosis or occlusion. e As a result, normal waveform patterns may persist distal to significant stenoses, indicating the presence of collateral circulation. e This finding suggests that adequate perfusion is maintained to the distal arterial segments despite the presence of obstructive disease proximally. When using the 4 cuff method to obtain segmental 30-40 mmhg pressures in the legs, the blood pressure in the proximal thigh normally exceeds the brachial e when performing the four cuff method of systolic pressure by mmHg. obtaining segmental pressures e the bp in the proximal thigh normally exceeds the brachial systolic pressure by ° 30-40 mmHG e The three cuff method yields a thigh pressure that should be © equivalent to the brachial pressure in a normal pressure Method Details Four Cuff The blood pressure in the proximal thigh normally exceeds the brachial systolic pressure by Method 30-40 mmHg. Three Cuff Yields a thigh pressure that should be equivalent to the brachial pressure in a normal Method condition. Parameter Observation Explanation Four-Cuff Proximal thigh pressure exceeds brachial Indicates normal pressure gradient using Method systolic pressure by 30-40 mmHg. the four-cuff method. Three-Cuff Thigh pressure is equivalent to brachial Reflects absence of gradient typically seen Method pressure in normal conditions. with the three-cuff method. A patient presents with left lower extremity pain that awakens him at night. The pain is relieved by C. 0.4 sitting at the side of the bed for a few minutes. What would the predicted ABI value be for the left leg? ABI Value Symptom Interpretation Above 0.9 Normal Typically no significant arterial disease. 0.5 - 0.9 Claudication Indicates moderate arterial disease, often presenting with pain during exercise. Less than Rest Pain Suggests severe arterial disease, with pain at rest due to poor blood flow. 0.5 Less than Critical Severe blockage, often requiring immediate medical intervention. 0.4 Ischemia Diagnostic Parameter Normal Criteria Ankle Brachial Index (ABI) 0.9:-1.3 Thigh Pressure 30-40 mmHg greater than brachial pressure; Thigh/ Brachial index > 1.2 Pressure in Adjacent Segments < 30 mmHg difference Pressure in Same Segment in Both Legs < 20 mmHg difference Toe/Brachial Index > 0.8 PSV (Peak Systolic Velocity) Change Between Less than a 2X increase Adjacent Segments Exercise Evaluation Lb 5 minutes or more of walking without symptoms  Upon cessation of exercise, the ankle pressures in D. decrease to normal levels in less than 5 minutes a normal patient will: e upon cessation of exercise » the ankle pressures in a normal patient will decrease to normal levels within 5 minutes = ankle and arm pressures should show a mild increase with exercise = bc they increase at relatively the same levels = the ABI usually stays the same or increases slightly Condition Explanation Ankle Pressure Post- Ankle pressures in a normal patient will return to normal levels within 5 minutes Exercise after cessation of exercise. Arm and Ankle Pressure Both ankle and arm pressures show a mild increase with exercise. Changes Ankle-Brachial Index (ABI) ABI usually stays the same or increases slightly because arm and ankle pressures rise at similar rates.. 126. Which of the following is a normal C. VASODILATION response from the capillary beds of the feet e resistance decreases in the capillary beds to and ankles after 5 minutes of vigorous allow an exercise? e increase in flow volume with exercise e normal arteries do not demonstrate any change in pressure with exercise 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. If you need any further assistance, please let me know!