Peripheral Vascular System Physical Diagnosis

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There are several points to remember prior to beginning the PVS examination. These include: 1. Taking complete vital signs of the patient. Take BP in both arms. 2. Palpate carotid pulse, auscultate for bruits. 3.  Auscultate for aortic, renal and femo ral bruits; palpate aorta, and determin e maximal diameter. 4. Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial arteries. 5. Inspect ankles and feet for color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin changes, hypertrophic nails. 6.  Assessment of the peripheral vascular system rel ies primarily on inspectio n of the arms and legs, palpation of the pulses, and a search for edema

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 – stenotic, occlusive, aneury smal dis of the aorta, its visceral arterial branches, and the arteries of the lower extremities, EXCLUSIVE of the coronary arteries  Age at risk = 50yrs or older and those w/ risk factors  Ask the following before starting the ex amination.

 Abdominal, flank or back pai n? (esp in older smokers) Constipation? Distention? Urinary retention? Diff voiding? Renal colic? Pain or cramping in the legs DURING exertion, relieved by rest w/in 10mins =

expanding hematoma may cause s/sx by compression of the bowel, aortic branches or ureters !

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sx limb ischemia w/ exertion pain w/ walking or prolonged standing, radiating from the spinal area into the buttocks, thighs or lower legs/feet

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Decreased ar  surface Gangrene =

Fatigue, aching, numbness, or pain that limits walking or exertion in the l Erectile dysfuntion Poorly healing/ non healing wound of the lower ex  Any pain at rest  Abdominal pain after meal s First degree relatives with AAA

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Coldness, numbness, pallor in the legs/feet, HAIR LOSS over ant. tibial surface.

ARMS BOTH arms from fingertips to shoulders. Note the ff: Size, symmetry, any swelling • Venous pattern • Color of skin and nail beds, texture of skin •

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lymphedema of arm and hand Venous obstruction = prominent veins in an edematous arm Raynaud’s disease = wrist pulses: NORMAL, sharply demarcated pallor of fingers

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Superficial inguinal nodes Note size, consistency, discreteness, tenderness? Non- tender, discrete, up to 1cm-2cm are frequently palpable in NORMAL people

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Palpate Feel for  (if you suspect arterial insuff) Feel for epitrochlear nodes These nodes are difficult or impossible to identify in most normal people

press deeply below the inguinal lig., and about midway between the ASIS and symphysis pubis

 WITHOUT ten

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Popliteal arte pulse  Arteriosclero circulation in Fe Po !

3+ 2+ 1+ 0

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BOUNDING BRISK, EXPECTED (NORMAL) DIMINISHED, WEAKER THAN EXPECTED ABSENT, UANBLE TO PALPATE

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dorsum of foot just lateral to the extensor tendon of the big toe

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curve fingers behind and slightly below the medial malleolus

LEGS

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Size, symmetry, swelling Venous pattern, venous enlargement Pigmentation, rashes, scars, ulcers Color and texture of the skin, nail beds distribution of hair on the lower ex Temp of feet and legs (use back of fingers)

warmth and redness over calf 

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absent pedal

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Sudden arteri limb distal to EM !

EXAMINATION OF THE PERIPHERAL V • •

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Look for edema pitting edema (use thumb, at least 2 seconds) over dorsum of each foot " behind each medial malleolus " over the shins " swelling: unilateral or bilateral? Venous tenderness that may accompany DVT? Color of skin Redness? o Brownish areas near the ankles? o Ulcers?

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syndrome !

tenderness in !

 just above th ! !

1.  With the use of flexible tap e, measure the: a. Forefoot b. The smallest possible circumference above the ankle. c. The largest circumference at the calf. d. The mid- thigh 2.  A difference of more than 1cm j ust above the ankle or 2 cm at the calfs’ un usual in normal p eople and suggest edema.

1. 2. 3.

Recent DVT Chronic venous insufficiency from previous thrombosis or incompetence of the valves Lymphedema

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Px standing, place palpating fingers gently on a vein, w/ the other hand below it and compress the vein sharply Feel for a pressure wave  A palpable pressure wave indi cates that 2 parts are connected !

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 (retrograde filling)  Can assess valvular competency in both the communication veins and the saphenous system Px supine Elevate one leg to about 90 deg to empty it of venous blood Occlude the great saphenous vein in the upper thigh  Ask the px to stand : saphenous vein fills FROM BELOW (about 35 sec)  After px stands for 20sec, release compression and look for sudden additional venous filling = •

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filling of the s occluded

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SPECIAL TECHNIQUES

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Ensure patency of the ulnar artery before puncturing the radial artery for blood sample collection  Ask px to make a fist with one hand Compress both radial and ulnar arteries firmly  Ask px to open hand in to a relaxed, slightly flexed position PALM IS PALE Release pressure over ULNAR artery If the ulnar artery is patent, PALM FLUSHES WITHIN about 3 to 5 SECONDS

Raise legs to about 60 degrees until maximal pallor of the feet develops (w/in 1 min)  Ask px to sit up w/ legs danglin g down, compare both feet: Return of pinkness of skin (N= !

Filling of veins of the feet and ankles (N = ) Look for any unusual rubor (dusky redness) = persistence means art. insufficiency !

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additional filli