14-1 Chapter 14 The Peripheral Vascular System

Multiple Choice

1. A 55-year-old disabled Vietnam veteran comes into the ER complaining of severe pain in his left arm, which occurred suddenly approximately 2 hours ago. He also states that the arm is numb and feels cold to him from the elbow down. He has had similar episodes in the past with his legs, which required amputation at the mid-thigh bilaterally. He has a 20-year history of hypertension and a 60-pack-year history of smoking. He is a recovering alcoholic but denies any drug use. His father passed away from a stroke at the age of 65. On exam, he is anxious and appears to be in a great deal of pain. The left arm appears pale and cool to the touch. No peripheral pulses in either the radial or ulna arteries are palpated. The pulses also cannot be elicited by Doppler. Reflexes in the brachioradialis tendon are decreased. He has decreased strength in his wrist and hand and cannot discern two-point discrimination. What peripheral vascular disorder best describes his situation?

(A) (B) (C) (D)

Artherosclerosis obliterans Acute arterial occlusion Deep venous thrombosis Cellulitis

2. A 42-year-old homemaker presents to your office complaining of swelling and pain in her right lower leg. She states it developed yesterday upon returning from a driving vacation to the Grand Canyon. She also informs you that she hiked and climbed all through the canyon with no pain in her legs or shortness of breath. Her past medical history is significant for one spontaneous

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vaginal delivery and one caesarean section for fetal distress. She is on a daily multi-vitamin and a low-estrogen birth control pill. She drinks socially one to two times a month and denies any tobacco or drug use. Her father has type-2 diabetes since his early 50s. On exam, you see that her right lower leg does look larger than the left. You measure 15 cm above the heel on each leg and find that the right leg is 3 cm larger than the left. There is no redness or heat over the calf. Placing your thumb over the tibia shows pitting edema. Palpating the back of her calf is negative for cords. What is the peripheral vascular disorder that best describes her problem?

(A) (B) (C) (D)

Acute cellulitis Raynauds disease Atherosclerosis obliterans Deep venous thrombosis

3. A 22-year-old female college student presents to your clinic for a post-hospitalization follow-up. She was admitted last week for appendicitis and had an appendectomy. She states that she is having no abdominal pain but is having pain on the back of her left wrist. She states that 2 days after she was discharged the area became painful, red, and swollen. She does think there was an IV line there, but she isnt sure. Her past medical history is non-significant and she denies any tobacco, drug, or alcohol use. On exam, the dorsum of her left hand is tender, warm, and red, with some minimal swelling. On palpation, you feel a hard knot 2 cm by 3 cm long. What is the peripheral vascular disorder most likely causing her problem?

(A) (B) (C) (D)

Raynauds disease Superficial thrombophlebitis Acute arterial occlusion Deep venous thrombosis

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4. A 68-year-old house painter comes to your office complaining of an ulcer on his right foot. He just noticed it yesterday, although he thinks it is quite large. He finds this strange because it doesnt hurt at all. He wears heavy work boots and does a good deal of climbing on ladders. He doesnt recall stepping on any nails. His past medical history is significant for 15 years of type-2 diabetes. He states the first 5 years following his diagnosis, he didnt take the medicine as he should have and that he is now on insulin shots. He also has 10 years of high blood pressure. He has smoked two packs of cigarettes for the last 50 years, but he denies recent alcohol or drug use. His family history is significant for a mother and aunt with high blood pressure and diabetes. On exam, you see a 2-cm ulcer over the plantar surface of the foot proximal to the great toe. There is callus formation around the edge of the ulcer. The patient is unable to distinguish vibration from pressure on his great toe. There are no color changes to his foot between elevation and dependency. What type of common ulcer best describes his problem?

(A) (B) (C)

Arterial insufficiency ulcer Venous insufficiency ulcer Naturopathic ulcer

5. A 75-year-old widow presents to your office complaining of a painful black spot to her left third toe. She states that it started smaller but has grown over the last few days. Her past medical history is significant for an acute myocardial infarction 6 years ago, with three-vessel bypass surgery afterwards. She has also had high blood pressure for 15 years and was diagnosed with type-2 diabetes last fall. She denies any tobacco, alcohol, or drug use. On review of systems, she does note that she is unable to walk a half-mile anymore without needing to stop due to pain in her legs. On exam, you find an elderly patient in no acute distress. She has no swelling or edema in her legs, although the skin color is fairly red. You can palpate a weak posterior tibia

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pulse but no dorsal pedis pulses. The toe in question is black the last distal centimeter. What peripheral vascular disorder is most likely the cause of her ulcer?

(A) (B) (C)

Insufficiency ulcer Venous insufficiency ulcer Arterial neuropathic ulcer

6. A 60-year-old homemaker presents to your office complaining of swelling to her left lower leg. She states that it has been developing over the last few weeks since her surgery for ovarian cancer. She has a past medical history significant for four spontaneous vaginal deliveries and the recent diagnosis of ovarian cancer. She denies any drug, tobacco, or alcohol use. On review of systems, she denies any chest pain, palpitations, or shortness of breath. On exam, you note that not only are her leg and ankle swollen but so are her toes. The skin appears to be thicker than usual, but there are no signs of ulceration. What cause of peripheral edema is the most likely in her case?

(A) (B) (C)

Pitting edema Chronic venous insufficiency Lymphedema

7. A 48-year-old unemployed man comes into the urgent care clinic complaining of increased swelling in his lower extremities. He states that he has had swelling for a number of months but that the swelling worsened last night. He complains of no ulcers or pain in the legs. His medical history reveals a past diagnosis of liver problems. He isnt sure what the exact diagnosis was. He states he used to drink a case of beer a night but he has recently cut back to a six-pack. He has smoked one pack of cigarettes a day for over 30 years and denies any IV drug use. On

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exam, you note that both legs are swollen, with no skin thickening or ulcerations. Pressing your thumb against his tibia reveals soft edema. Auscultation of his lungs reveals no crackles. His heart sounds are regular, with no murmurs, rubs, or gallops. His abdomen reveals a small liver but no discernable fluid wave. What diagnosis of peripheral causes of edema is most likely the cause of his problem?

(A) (B) (C)

Pitting edema Chronic venous insufficiency Lymphedema