Case+4

__Case #4__ Looking at these PVR waveforms answer the following questions:


 * Do they look normal? Describe what’s normal or abnormal about them.**

Jess: The waveforms on the right look normal but the waveforms on the left look abnormal for the thigh area. A normal waveform should have a steep upstroke, with a dicrotic notch. The waveform in the thigh doesn't have a notch.

Madeline: The waveforms on the right look normal because they sharp systolic peak and a dicrotic notch. The left side doesn't look as good. The waveform in the left thigh still has a pretty steep upstroke but it has lost its dicrotic notch. It also kind of has a flattened systolic peak which represents a moderately abnormal waveform. Another thing I look at to help me decide if a waveform is abnormal or not, it to look at the comparison in pressures. If one waveform has a sharp upstroke and dicrotic notch, it can be helpful to compare the two sides and see what is different about them.

Danielle: The right side waveforms on this patient seem normal. When grading waveforms you should see a sharp systolic peak with a dicrotic notch in a normal waveform, like we see on the right side. When you have a mildly abnormal waveform, you will see a sharp peak and loss of the dicrotic notch. Then with moderately abnormal you will see a flattened systolic peak and with severely abnormal you will see low amplitude waves. On the left side, the first waveform in the high thigh looks normal but when we get into the area above the knee the waveform there is the loss of the dicrotic notch, suggesting a mildly abnormal waveform. 

Jess: PVR waveforms are obtained by placing cuffs on the different segements of the legs. Then you use either the dorsalis pedis or posterior tibial artery (whichever gave the higher reading from the ABI's, with the pencil probe. Once at a time, inflate the cuff until there is no Doppler signal and then wait until you see a Doppler signal return.
 * How are PVR waveforms obtained?**

Madeline: Pulsed volume waveforms are obtained by putting cuffs on the high thigh, low thigh, calf, and ankles. Then there is an automatic inflation of the cuffs bilaterally, so when the right ankle cuff inflates so does the left ankle cuff) and when the waveform returns you document that and move to the next segment.

Danielle: PVR waveforms are obtained by placing pneumatic cuffs around the lower extremities at specific sites; high thigh, low thigh, calf, and ankles. One is also placed on each arm for brachial pressures. The cuffs automatically inflate to 60-65 mmHg. Two cuffs are inflated at one time, one from the right side and the same segment on the left side. A pressure transducer converts the pressure changes into an analog waveform. Jess: The movement or pulse of the artery through that segement of the artery.
 * What exactly does the wave represent?**

Madeline: PVRs represent the volume of blood moving through the vessel.

Danielle: The wave represents the arterial flow moving under the cuff.