Aligned with the American Association of Nurse Practitioner and American Nurses Credentialing Center format. Authored & peer-reviewed by Adult-Gerontology Primary Care NPs.
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A 50-year-old man presents to the clinic with dizziness. He has a history of hypertension, hyperlipidemia, and diabetes mellitus. He states that, in the last week, he has had increased dizziness, noticed floaters in his vision, and occasionally loses vision in one eye for brief moments. Which of the following components of the physical assessment will most likely assist in identifying the suspected diagnosis?
Carotid artery disease precipitates approximately 20% of ischemic strokes. The bifurcation of the common carotid artery in the bulb region is typically where atherosclerotic carotid stenosis originates. Conditions near the bulb that increase contact time between lipids and the vessel wall include flow separation, low shear stress, and nonlaminar flow. As the plaque gradually enlarges, cerebral perfusion can be interrupted or reduced due to narrowing or occlusion of the internal carotid artery. Additionally, turbulent blood flow of the atherosclerotic carotid arteries can cause damage to the plaque, resulting in ulceration or loss of intimal continuity. Thrombosis results from platelet and fibrin aggregation on the roughened intimal surface. Interruptions in cerebral blood flow result in clinical manifestations such as dizziness, vision floaters, fleeting attacks of monocular blindness, numbness of the contralateral extremity, dysarthria, and aphasia. Risk factors of carotid artery disease include hypertension, hyperlipidemia, diabetes mellitus, smoking, physical inactivity, chronic kidney disease, heavy alcohol consumption, and sleep apnea. The risk of carotid artery disease increases significantly after the age of 50. Physical examination should include a complete neurologic and cardiovascular assessment. Auscultation of the carotid arteries for bruits is a marker for generalized atherosclerosis and should be assessed in patients with and without clinical manifestations of carotid stenosis. Carotid bruits have low sensitivity for the detection of carotid stenosis, which is why symptomatic patients should undergo diagnostic studies. Duplex ultrasound of the carotid arteries is the chief diagnostic tool for carotid stenosis. Asymptomatic patients with carotid bruits should also receive a carotid ultrasound. Patients with carotid stenosis should be referred to a surgeon for a possible carotid angioplasty with stenting or a carotid endarterectomy.
Assessment of cranial nerves III, IV, and VI (A) should be included in this patient’s physical assessment, but carotid auscultation is more likely to reveal carotid stenosis. Assessment of dorsalis pedis pulses (B) should be included in the physical assessment due to the patient’s medical history but is not likely to reveal carotid stenosis. Palpation of the abdomen for an aortic aneurysm (D) is recommended in the periodic health examination of men over age 65 years. Patients with an abdominal aortic aneurysm typically present with abdominal or flank pain with a pulsatile abdominal mass.
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Transient Ischemic Attack
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