Principles of the Vascular Exam

8/13/2019 Principles of the Vascular Exam

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PHYSICAL EXAMINATIONof the

VASCULAR SYSTEM

Hugh Gelabert, M.D.

Vascular Surgery Division

UCLA School of Medicine


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Todays Objective

To review the examination of the

Vascular System

To review exam techniques

To discuss common findings

To review the correlation between

patient symptoms and exam findings


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Goal of Medical History

To record the patients symptoms at

time of presentation.

To organize the events which have leadto presentation.

To summarize the evidence which

supports diagnostic hypothesis.

To provide basis and direction for care.


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Goals of Physical Exam

To record the state of patients health atthe time of the examination.

To provide a longitudinal record of thepatients health.

Allow assessment of progression of

disease. Allow prognostication of natural history.

Allow recommendations for care.


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Arterial Anatomy

Goals

establish presence and quality of pulses

establish presence or absence of findings:aneurysms, arterial bruit, signs of ischemia,

signs of venous disease

Vascular Physical Exam


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ARTERIAL ANATOMY


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ARTERIAL ANATOMY


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ARTERIAL ANATOMY


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Posterior Tibialis

Dorsalis Pedis



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Femoral Artery

Popliteal Pulse



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Aortic Aneurysm Exam



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Subclavian Artery Exam



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Carotid Artery Exam



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Bruit

Sound made by vibrating arterial wall

Caused by turbulent blood flow making

arterial wall vibrate

Indicates the presence of an arterial

lesion



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Vascular Findings

Generally related to

Blockage of blood vessel

Dilatation of blood vessel

Subsequent events

Ischemic tissue

Gangrenous tissue


V l Ph i l E


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Ischemia

Decreased blood supply results in

metabolic compromise.

Grades of severity reflect acuity ofcondition as well as the magnitude of

the reduction in circulation.

ACUTE vs CHRONIC


V l Ph i l E


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Acute Ischemia

5 Ps

Pulseless

Pain

Pallor

Paresthesia

Paralysis Poikilothermia (Cold)



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Acute Ischemia

V l Ph i l E


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Acute Ischemia

An abrupt disruption of the normal blood

supply to a vascular bed.

Example: Gunshot wound

Fracture

Tourniquette Embollus


V l Ph i l E


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Acute Ischemia

Implies that without prompt restoration

of blood supply there will be significant

permanent damage to tissues. Susceptibility to Acute Ischemic Injury

Nerve +++

Muscle ++

Tendon and Bone +


Vasc lar Ph sical E am


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Chronic Ischemia

A process where the gradual onset and

magnitude of ischemia has allowed the body

time to compensate for the decreased bloodsupply.

Key Concept: Collateral Circulation

Compensation is never as good as original.

The vascular bed survives with less blood.




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Chronic Ischemia

Changes in the Limbs

Skin ...Growth slowed

Nails beds Growth slowed

Hair follicles .Lost

Sebaceous glands Lost

Result: Thin, dry, skin with loss of hair,abnormal nail growth / fungal infections.




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Capillary Refill

The time required for capillary system to refillfollowing compression of the nail bed orfinger pad.

Normal should be rapid (1 sec or less)

Decreased Normal physiologic response (eg. cold)

Abnormal vasomotor tone (eg. Raynauds) Acute Ischemia

Chronic Ischemia




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Capillary Refill

In the chronic ischemic limb:

Pallor on Elevation

Insufficient arterial pressure to perfuse whenleg elevated above level of heart.

Limb drains of blood.

Dependent Rubror

Blood pooling in maximally dilated capillary bed

Cyanosis -- when blood is de-oxygenated



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Tissue Refill

Buergers testVenous Guttering



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Capillary Refill

In Acute Ischemia

Cyanosis noted because blood hemoglobin is

desaturated of oxygen

Compression of digit results in evacuation of blood

from capillaries

Refill of blood is sluggish because of decreased

arterial pressure.

In severe cases the blood in capillaries may

thrombose and will not blanch on palpation



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Cyanosis with acute ischemia



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Ulceration

A discontinuity in the integrity of the skin

which persists despite sufficient time for

healing. Must be able to distinguish three types:

Arterial, Venous, Neuropathic.



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Ulcers

Differential Presentation of Ulcers

Arterial Venous NeuroLocation distal maleolar plantar

Symptoms painful + / - no pain

Outline sharp irregular punched

Assoc findings Art sx CVI sx other Dxno pulse OK pulse OK pulse


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What kind of ulcer ?


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Neuropathic

Plantar

location

Punched

Out

margins

Insensate


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Arterial Ulcer

Distal

location

Sharp

margins

Painful


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Venous Ulcer

Maleolar

location

Irregular

margins

Insensate

or Painful


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Ulcers

DIABETIC

VENOUS

ARTERIAL


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Decubitus Eschar

Gangrene:Necrosis or death of tissue.



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Gangrene

Death of tissue

Related to absent blood supply

Infections Tissue Toxins

Radiation, Trauma

WET Gangrene vs DRY Gangrene

Bacterial superinfection

Mumefaction or mumyfication

y


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Wet Gangrene


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Dry Gangrene


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Gangrene

A dynamic process develops

where tissues becomes ischemic

with acute necrosis, autolysis andliquefaction.

In the absence of superinfection

the tissue gradually dessicates

and becomes mummyfied. Later,

eschar separation and auto-amputation take place.


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Blue Toe Syndrome


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Digital Embolizationa



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Process of Auto Amputation

Dry Gangrene of Digit

Tissue dessicates

Demaracation Eschar separation

Epidermal ingrowth

Wound margin contraction Osteolysis


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Auto-amputation



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Methods:

Prepare your patient for exam:

be sure room temperature is correct

be sure limb position is as needed be sure privacy is respected

place patient in correct position: supine on

exam table is generally best uncover area to be examined



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Methods:

Discuss what you are about to do

inform patient of intention ofexamination

explain how exam will be conducted



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Methods:

Prepare Yourself for the Exam

approach exam systematically

compare bilaterally

review patient complaints as exam

progresses



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Methods:

Follow Exam Sequence

observe

auscultate

lightly touch

palpate

compress



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Specific Observations

PULSES

-- should note 17 pulses.

-- quality (-, +, ++)

Temporal x 2

Carotid x 2

Brachial x 2

Radial x 2

Aorta x 1

Femoral x 2

Popliteal x 2Dorsalis Pedis x 2

Posterior Tibialis x 2



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ANEURYSMS

-- should examine for 5 aneurysms

Aorta x1

Femoral x2

Popliteal x2




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BRUIT

-- should listen for 5 bruit.Carotid x2

Aorta x1

Femoral x2




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SIGNS OF ISCLEMIA

-- look for 6 Ischemic Signs in each limb.

Color Temperature

Capillary Refill UlcerationEschar Location




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VENOUS SIGNS

-- look for 5 Venous Signs in each limb

Brawny Color Varicose Veins

Ulceration Edema

Location



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Evidence Testing

Scenario #1: Patient complains of calf claudication

Scenario #2: Patient complains of thigh claudication Scenario #3: Patient complains of buttock claudication

Scenario #4: Patient complains of leg swelling

Scenario #5: Patient complains of cold feet

Scenario #6: Patient complains of pulsatile mass in abdomen


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Evidence Testing

Scenario #1:

Patient complains of calf claudication

Consider that the ischemic symptom develops in the

affected muscle bed.

The affected muscle bed lies downstream from the

causative lesion.


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Evidence Testing

Scenario #1:Patient complains of calf claudication

Femoral pulses would be present Distal (DP / PT) would probably be absent

Popliteal pulses may be present, but more commonlythe arterial lesion is in the SFA and the popliteal

pulse is absent.

Distal signs of chronic ischemia would be present



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Student Worksheet -- Specific Observations

1. Pulses -- should note quality (-, +, ++)

right left

_____ _____ Superficial Temporal

_____ _____ Common Carotid

_____ _____ Brachial

_____ _____ Radial

_____ Aorta

_____ _____ Common Femoral

_____ _____ Popliteal_____ _____ Dorsalis Pedis

_____ _____ Posterior Tibialis

2. Aneurysms (yes, no)

right left

_____ Aorta


_____ _____ Popliteal

3. Bruit (yes, no)

right left


_____ Aorta


4. Ischemic Signs -- signs of arterial disease.

(normal, abnormal; yes, no; If yes, location)

right left

_____ _____ Color

_____ _____ Temperature

_____ _____ Capillary Refill

_____ _____ Ulceration

_____ _____ Eschar

Location

5. Venous Signs -- signs of venous disease.

(yes, no. If yes, location)

_____ _____ Brawny Color

_____ _____ Varicose Veins


_____ _____ Edema

Location

Examination Instrument


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Conclusion

Reviewed the Vascular exam

Reviewed exam techniques

Discussed common findings

Discussed relation between patient

symptoms and exam findings

Next step Med West



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PE Module -- Organization

Med West clinical examination facility

exam rooms available today

model patients

All normal exams

Goal: Practice normal exam on different

patients

Goal: Practice self-evaluation


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Student Worksheet -- Specific Observations

1. Pulses -- should note quality (-, +, ++)

right left

_____ _____ Superficial Temporal


_____ _____ Brachial

_____ _____ Radial

_____ Aorta


_____ _____ Popliteal_____ _____ Dorsalis Pedis

_____ _____ Posterior Tibialis

2. Aneurysms (yes, no)

right left

_____ Aorta


_____ _____ Popliteal

3. Bruit (yes, no)

right left


_____ Aorta


4. Ischemic Signs -- signs of arterial disease.

(normal, abnormal; yes, no; If yes, location)

right left

_____ _____ Color

_____ _____ Temperature

_____ _____ Capillary Refill


_____ _____ Eschar

Location

5. Venous Signs -- signs of venous disease.

(yes, no. If yes, location)

_____ _____ Brawny Color

_____ _____ Varicose Veins


_____ _____ Edema

Location

Examination Instrument



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Did the student examine and record the following?

YES NO

_____ _____ 17 pulses

_____ _____ 5 aneurysms

_____ _____ 5 bruit

_____ _____ 6 sings of arterial disease

_____ _____ 5 signs of venous disease

_____ _____ explain examination procedure

_____ _____ position patient correctly

_____ _____ uncover the skin of the part to be examined.

_____ _____ inspect

_____ _____ auscultate with stethoscope on skin

_____ _____ touch skin (no through clothing or dressing)

_____ _____ palpate for aortic aneurysm between umbilicus and xyphoid

_____ _____ palpate for popliteal pulse or aneurysm with two hands

_____ _____ stand at foot of patient while palpating dorsalis pedis and posterior tibial

_____ _____ compress ankle to assess edema

_____ _____ feel toes to asses temperature

_____ _____ press toes to asses refill

Totals: _____ _____

Assessment Instrument

Documents

Principles of the Vascular Exam