Carol Berger: Welcome to Week 4 with our clinical pearls. Today we are going to talk about our peripheral and cardiovascular system. We are going to talk a little bit about things that are unique to these systems and some interesting cases that I had in my practice.
Just a tip for you: remember that the course you are taking in 612 is on assessment, so you want to make sure with each of these systems that you know the vocabulary that goes along with it, you know what you are assessing and why you are assessing it, you know tests that are associated with that system and what they are for, and that you know your instruments and how to use them as well as knowing the parts of documentation and how to document it correctly.
Now with the peripheral vascular disease and the cardiovascular disease, we’re going to talk about some of the different signs you are going to come up with and tests that you would do with some of these cases that we did to find out what was wrong.
Let me ask you a few questions just to get started. What are the symptoms of peripheral vascular disease? I guess some of the symptoms that I see in practice whenever I see people who have bilateral swelling of both legs I think, ‘We may have venous insufficiency,’ and what causes venous insufficiency is sometimes it could be associated with congestive heart failure, but most of the time it has to do with lower extremity dependent type edema or lymphedema. The valves in the legs have become insufficient. They are not letting the fluid get back up where it is supposed to so it begins to accumulate in the lower parts of the legs. They may also have some low albumin that is attributing to the leakage of the fluid and to that third space, but a lot of times that is what you see. What helps with peripheral vascular disease is we see clinicians all the time prescribing Lasix for edema. On that type of edema Lasix doesn’t help that much. You can certainly tell the patients to increase their protein intake if there albumin is low and that will help pull some of the fluid out (and watch their salt—that will help), but mainly our mainstay of therapy with venous insufficiency is compression stockings, wrappings, exercise, sequential pumps that help to get the fluid back where it is supposed to go.
Then the next question I have for you is what are the symptoms of peripheral artery disease? How do you know the difference between peripheral artery disease and peripheral vascular disease? Because they may have a combination of the two. I had one patient to just say, ‘It just hurts to stand on my feet.’ Now this was a very overweight person. She had lymphedema. She was on a lot of medications because she had bipolar and one medication that really pulls a lot of water into your legs is gabapentin or Neurontin, so we had taken her off of that. Lasix would help maybe for a day or so, but she really complained of her feet hurting her and we thought maybe she had planned to fasciitis, but we did an arterial brachial index on her—not venous Doppler, but arterial Doppler on both of her legs and found out she had the beginnings of peripheral artery disease, so your symptom of peripheral artery disease was claudication. What was she complaining of? “My feet hurts, it hurts when I stand. I can’t stand on my legs, they have so much water in them all the time they hurt. I have to sit down.”
It wasn’t the traditional complaint claudication that you would think where she was saying, ‘Oh, as soon as I start walking my legs hurt and I sit down and I feel better,’ and then you go ‘Oh, bingo, that’s claudication and peripheral artery disease.’ She was complaining ‘I have so much water in my legs its making my legs hurt. It hurts when I stand on my feet.’ The way she was presenting was not the way it would make you investigate maybe peripheral artery disease, and she was young, but yes she did have the beginnings of peripheral artery disease and that was what was causing her pain in her legs which was claudication, so we got her hooked up with a peripheral vascular surgeon who will monitor her and help her to do things. Obviously losing weight is going to help with some of that and the medications being changed with some of that will help with that, but they will be able to watch it. When it gets to a certain point they will be able to intervene.
The next question I have for you is a difference between a Baker’s cyst versus a DVT, and I have both of these in my office. Baker’s cyst are small, little cyst-like structures behind the knee, and if they pop they can cause a bunch of fluid to leak into the bottom part of the leg and they will hurt when they walk, so when they present to you, you are going to have one leg swollen. You’re going to have pain with walking. How can you tell the difference from a Baker’s cyst or DVT? The answer is you can’t. You have to do a venous Doppler, and that will tell you the difference. Now if there is not a DVT there the treatment for a Baker’s cyst is to wrap it. The fluid will eventually then get reabsorbed, and if you can catch a Baker’s cyst before it pops they can take them out.
Then my last question is cellulitis. How do you know if it is just redness and skin changes versus cellulitis, and the answer is you know the difference because cellulitis is painful. When you touch it, it hurts. Chronic skin changes don’t. They can’t get chronic skin changes from just having water in their legs all the time and from a variety of different diseases, but the cellulitis is redness with warmth and pain. It hurts when you touch it.
The last question I have for you is does lotion help prevent cellulitis with chronic venous stasis dermatitis, and the answer is absolutely! You have somebody who has chronic venous stasis dermatitis, not areas where it’s weeping and open, but the other areas, if they will put lotion on their legs every day between their toes it really helps to increase the integrity of that skin. It helps that skin be a better barrier. The skin has already thinned out because of the water. The last thing it needs to be is dried out, and then they get cracks and now the cracks go into the water that is there and then you have a cellulitis that is recurrent, so, yes, the answer is that lotion definitely does help. I always tell my patients to put lotion who have chronic lymphedema on their legs every day.
Now let’s talk about some interesting cases. I’ve got about five of them for you. This was a woman who came in complaining of pain in her left lower leg. It had really been going on for the last several weeks. She noticed increasing pain in this left lower ankle area where several years ago she had had surgery. She had some hardware there, and she had noticed this thick-feeling skin over the medial area. She was really concerned about a blood clot because it hurt when she walked, so what was she feeling? She was feeling claudication, and she was having—you know, when I looked at it I was concerned that she may have a blood clot there as well.
I was concerned enough that I gave her a prescription for Eliquis and I gave her a sample to start before we could get the ultrasound to make sure about the blood clot, so I started her on—you will get samples and I gave her the starting dose of it and I said, ‘Well, we’ll get this ultrasound done later on this afternoon but go ahead and take this,’ because it protects them within 2 hours. Actually within 2 hours to have protection from something like Eliquis. If it turned out to be negative and she just wouldn’t take any more. Within 24 hours she would be back to her levels, so when they went in there and they were looking the interesting thing about her cases it was not a blood clot where we thought it would be, which was around the ankle. She did however have a blood clot that was all of the way up into the femoral area, so it very well could have been a blood clot that had started at her ankle and had gone up her leg and kind of got stuck in that bifurcation and just having traveled beyond that yet, so she was actually very lucky and we already had started her on the medication. With Eliquis they don’t have to have any bridging, so we just dosed it for a DVT the way you would dose it for a DVT, and she was fine.
Now the question becomes why did she get the blood clot to begin with? That is a whole different conversation, but that was an interesting kind of case.
This is another case actually we had in the hospital, and it was a really a nurse who was very into with her physical exam that picked up on this, but this is a 54-year-old woman who came into the hospital with left-sided chest pain, left arm pain. She was admitted for chest pain rule out.
We had a negative cardiac workup, though. I mean all of her troponins were fine. Her stress test was fine. Everything looked good, but she was still having this left arm pain, so what is causing this left arm pain? Well, normally you would think it would be her cervical spine and that is what everybody was kind of, ‘Okay, we’ve got to do a CT of her spine to see if her cervical spine is pinching something, causing that nerve pain. We can check the electrical conduction in that arm,’ so that is the path that most of us were going on, but what the nurse noticed was that she had a slightly weaker pulse in that left hand and the left hand was just a little bit cooler.
So we did a venous Doppler, arterial Doppler, on that left arm and what we found was that she had an ulnar arterial occlusion, so the brachial area was fine, okay, but the ulnar side was blocked off, so that is why she still had a pretty decent pulse, but it just was a slight bit weaker. Actually they did a thrombectomy, and they gave her medication to break up the clot and they did the thrombectomy to get that pulsed come back. So sometimes left arm pain could be, you know, a DVT which is what she—not a DVT, but she had an arterial occlusion and that was causing the pain.
Okay, this is the next case. This took actually about 2.5 years to totally diagnose this person. The best most interesting case in my entire career in the past 10 years as far as cardiac goes. This was a woman who was in her 50s. She had actually had a car accident about 6 months before when all of this kind of started. She was complaining of feeling faint, like she was going to pass out every time she went to the bathroom to have a BM. It actually was so bad that at this point she was afraid to go to the bathroom to have a BM because it would wipe her out for the rest of the day. It was to the point where she was needing to get FMLA because it was affecting her job and she was the manager of the place. It had been going on about 6 months and she just didn’t know what to do about it.
So the first thing you think of, ‘Oh, well she’s just vasovagaling,’ right? Will the first thing you’re going to do is due and EKG in the office, which is what I did, but I noticed that at baseline she had a heart rate of about 46 on that EKG and she was asymptomatic, so I could only imagine that if she was bearing down to have a bowel movement that that heart rate will go down even more. So the first thing I did was put a Holter monitor under and I sent her to cardiology. Also, her family history said that she had several relatives who had pacemakers, so that was my concern, that she’s got some kind of a defect in her heart and it’s just not pacing right. It’s getting down to low and is causing her to have a syncopal episode.
So we put a Holter on her and did it for 2 weeks and we did it for 30 days and we didn’t capture anything other than some bradycardia. You know, like she would get down into the 40s, so that was concerning, so they sent her to an electrophysiologic cardiologist, and he did—I think he was the one that ordered the 30-day Holter monitor and couldn’t pick up anything, so he, for some reason, figured that it wasn’t her heart and he thought maybe it was something to do with her stomach, so he sent her to a GI doctor so that she had a complete upper and lower GI which was negative for anything. At this point she was pretty discouraged. Now obviously we checked her thyroid. We checked all of the things that you would think that might cause her heart rate to go low. We’ve done all of the standard tests. She’s had a stress test. She’s had an echo. She’s had carotid Doppler. She’s had a Holter monitor twice.
She had an episode at work where they brought her directly over to my office and she was—like it was hard to even get her to wake up and we got her to the hospital. We called the ambulance and got to the hospital and by the time she got to the hospital she was awake and feeling much better and everything was fine.
So now she’s back. They’ve got her seeing psychiatry because obviously she’s a woman and she’s got some kind of anxiety issue going on that might be causing all of this, and she’s that super depressed because at this point she has lost her job. The FMLA only goes for so long and that they can fire you anyway and they had to let her go because she just wasn’t at work enough.
Finally she came back in and she saw me again because she was bouncing around from one doctor to another doctor to another doctor and I convinced her that if the first cardiologist wasn’t listening to her that we needed to find another one, and I told her there were still other things that needed to be done. She needed to have a tilt table test done and maybe there was a better way they could see what was happening when she was having these episodes, so to make a long story short what they did was they put in what is called a Reveal Monitor, and that is something that goes underneath the skin. It gets placed right underneath the skin and it is like a Holter only it is closer to the heart.
In this woman’s case, the external Holter monitor just was not sensitive enough to pick up what was going on, and when she was having a bowel movement she was going into a fine atrial flutter, and that was wiping her out for the rest of the day. Once they could see this on the monitor and what was happening they were then able to schedule her for an ablation and they did the ablation and she was completely cured of symptoms.
Now she still does have some symptoms. They did diagnose her with Pott’s disease, and I encourage you to look that one up. That is the postural hypotension syndrome, and she did have that, so she definitely needs to wear compression stockings and things like that to help keep her blood pressure up, but she had another anomaly that made it go over the top, so she’s back to work now and doing much better. She still has some symptoms but nowhere near what she had before, and it did take an extended period of time to figure out exactly what was going wrong with her.
This is another case. This one is a person who is complaining of chest pain. She was lifting boxes at work and had pressure in her chest with some shortness of breath. She says she sat down and it felt better. Now the interesting thing with her is she has a history of 6 steps, so she’s got a lot of cardiovascular disease. My question to you would be what are you going to do with this person, what tests do you want with this person?
You already know she has coronary artery disease and it is significant. If you did a stress test, which you believe the results? You’ve got to answer no. She had a stress test and it was negative with a history of 6 stents and with history of pressure in her chest with shortness of breath that gets better when she sits down and worse with exertion you are going to think she’s got some kind of blockage. Barring the fact that she had had a recent any type of catheterization within the last year, you will probably say that the cardiologist is going to want to do the catheterization, and that is correct. I called her cardiologist. I told him of her symptoms, and he told me just to have her come in the next day and he would have her go straight to the Cath Lab and they would catheterize her, and they did, and she did have 7 stents when they got done. That is my clinical pearl for you. If they have no history of coronary artery disease you can certainly go through stress tests and all of those things, but you have to remember those are screening tests, they aren’t definitive. The only definitive test in angiography is the cardiac catheterization. I mean the other ones aren’t looking directly at the heart. They’re just giving you an indication of the risk stratification tests, so if you know they have severe coronary artery disease, it might be good for you just to pick up the phone and talk to somebody—talk to their doctor and see what they want to do.
Okay, this one, not dizziness. Dizziness is a very generic complaint. ‘I’m dizzy.’ This is a 67-year-old female who states every time she bends down to change the kitty litter she feels dizzy, and that she says ‘You know, and sometimes I have a little bit of chest pressure with it but it goes away.’ But when you examine her you hear a loud holosystolic murmur that radiates to her right neck.
Now if you know your anatomy and your thinking about your murmurs, if it is going to the right neck you’ve got something going on with the aortic valve. What she is complaining of is dizziness, so that might mean the blood flow is not getting through, and that is causing some chest pressure and we’ve got this loud murmur going to her right neck so we are concerned about a valve. One of the valves in her heart is not working correctly and we think it is probably the aortic valve, so my next question is what test do you want?
What you want is an echocardiogram. Echocardiograms are what diagnose valvular problems, right? This particular woman came back. I got called by the cardiologist and he said, ‘You found hypertrophic cardiomyopathy.’ Well what does that mean? Hypertrophic cardiomyopathy is one of those genetic things, one of the things that cause sudden death. This woman had a congenital abnormality from the time she was born, something with the septum was too thick and it causes this obstructive cardiomyopathy. It is not because she has a weak heart but because of the way her heart is shaped. It’s really a good one for you to look up about hypertrophic cardiomyopathy. Again UpToDate is a great resource for you. What they actually were able to do for her is just to give her a little bit of a beta blocker and it actually took away most of her pressure and problems and they monitor a little more—about every year or two they will do another echo, and she is managed by cardiology for this, but it was a real interesting thing because she really did not have any type of cardiac problems and it was picked up on physical exam combining it with her symptoms.
Last but not least we’ve got another dizzy person. This is a 76-year-old female. She has had a CABG, but she has been complaining of increasing episodes of chest pain, shortness of breath, dizziness, and when you listen to her again you hear this loud murmur radiating to the right axilla, so I’m concerned with her aortic valve. The echo shows she has aortic sclerosis, which has got a little bit better prognosis than aortic stenosis. The sclerosis has got just a little bit better prognosis, but when her blood pressure gets around 120/80 she gets dizzy, so that is my question to you right now. Why would she get dizzy when her blood pressure gets to 120/80?
The answer is with the aortic valve being sclerotic, not working as well, she needs that pressure to push the blood through, and if we get it down to low it’s just not able to push it against her that sclerotic valve, so that is what causes her dizziness and can cause her shortness of breath and some chest pain. So you want her blood pressure to be a little more closer to the 140/80–90 range so she has enough pressure there. This particular woman actually continued to get more and more symptomatic, and even though her age was against her, they did go in and do a valvular surgery on her which did end up extending her life another 3–5 years I think for sure with less symptoms and kept are much more active, but it was touch-and-go with the surgery and it had to be the right surgeon to be able to do the surgery on her.
Those are all of the cases I’ve got for you this week. I will talk to you later.