Download - PHYSICAL EXAMINATION of the VASCULAR SYSTEM
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PHYSICAL EXAMINATIONof the
VASCULAR SYSTEM
Hugh Gelabert, M.D.
Vascular Surgery Division
UCLA School of Medicine
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Today’s 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 patient’s symptoms at time of presentation.
• To organize the events which have lead to 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 patient’s health at the time of the examination.
• To provide a longitudinal record of the patient’s 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
Vascular Physical Exam
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Femoral Artery
Popliteal Pulse
Vascular Physical Exam
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Aortic Aneurysm Exam
Vascular Physical Exam
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Subclavian Artery Exam
Vascular Physical Exam
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Carotid Artery Exam
Vascular Physical 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
Vascular Physical Exam
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Vascular Findings
• Generally related to – Blockage of blood vessel – Dilatation of blood vessel
• Subsequent events– Ischemic tissue– Gangrenous tissue
Vascular Physical Exam
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Ischemia
• Decreased blood supply results in metabolic compromise.
• Grades of severity reflect acuity of condition as well as the magnitude of the reduction in circulation.
• ACUTE vs CHRONIC
Vascular Physical Exam
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Acute Ischemia
• 5 ‘P’s– Pulseless– Pain– Pallor– Paresthesia– Paralysis– Poikilothermia (Cold)
Vascular Physical Exam
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Acute Ischemia
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Acute Ischemia
• An abrupt disruption of the normal blood supply to a vascular bed.
• Example: • Gunshot wound• Fracture• Tourniquette• Embollus
Vascular Physical Exam
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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 +
Vascular Physical Exam
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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 blood supply.
• Key Concept: “Collateral Circulation”• Compensation is never as good as original.• The vascular bed survives with less blood.
Vascular Physical Exam
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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.
Vascular Physical Exam
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Capillary Refill
• The time required for capillary system to refill following compression of the nail bed or finger pad.
• Normal should be rapid (1 sec or less)• Decreased
– Normal physiologic response (eg. cold)– Abnormal vasomotor tone (eg. Raynaud’s)– Acute Ischemia – Chronic Ischemia
Vascular Physical Exam
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Capillary Refill
• In the chronic ischemic limb:– Pallor on Elevation
• Insufficient arterial pressure to perfuse when leg elevated above level of heart.
• Limb drains of blood.
– Dependent Rubror• Blood pooling in maximally dilated capillary bed• Cyanosis -- when blood is de-oxygenated
Vascular Physical Exam
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Tissue Refill
Buerger’s 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
Vascular Physical Exam
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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.
Vascular Physical Exam
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Ulcers
Differential Presentation of Ulcers
Arterial Venous Neuro
Location distal maleolar plantar
Symptoms painful + / - no pain
Outline sharp irregular punched
Assoc findings Art sx CVI sx other Dx
no 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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What kind of ulcer ?
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Arterial Ulcer
Distal location
Sharp margins
Painful
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What kind of ulcer ?
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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
Vascular Physical Exam
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Wet Gangrene
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Dry Gangrene
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Gangrene
A dynamic process develops where tissues becomes ischemicwith acute necrosis, autolysis andliquefaction.In the absence of superinfectionthe 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
Vascular Physical Exam
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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
Vascular Physical Exam
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Methods: Discuss what you are about to do
• inform patient of intention of examination
• explain how exam will be conducted
Vascular Physical Exam
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Methods: Prepare Yourself for the Exam
• approach exam systematically
• compare bilaterally
• review patient complaints as exam progresses
Vascular Physical Exam
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Methods: Follow Exam Sequence
• observe
• auscultate
• lightly touch
• palpate
• compress
Vascular Physical Exam
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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 2
Dorsalis Pedis x 2
Posterior Tibialis x 2
Vascular Physical Exam
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ANEURYSMS
-- should examine for 5 aneurysms
Aorta x1
Femoral x2
Popliteal x2
Vascular Physical Exam
Specific Observations
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BRUIT
-- should listen for 5 bruit.
Carotid x2
Aorta x1
Femoral x2
Vascular Physical Exam
Specific Observations
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SIGNS OF ISCLEMIA
-- look for 6 Ischemic Signs in each limb.
Color Temperature
Capillary Refill Ulceration
Eschar Location
Vascular Physical Exam
Specific Observations
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Specific Observations
VENOUS SIGNS
-- look for 5 Venous Signs in each limb
Brawny Color Varicose Veins Ulceration Edema
Location
Vascular Physical Exam
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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
Vascular Physical Exam
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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 commonly
the 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
_____ _____ Common Femoral _____ _____ Popliteal
3. Bruit (yes, no)
right left_____ _____ Common Carotid
_____ Aorta _____ _____ Common Femoral
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 _____ _____ Ulceration _____ _____ Edema
Location
Examination Instrument
Vascular Physical Exam
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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
Vascular Physical Exam
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PE Module -- Organization
• 34 students
• 8 model patients
• Students subdivide into Groups of 4
• 4 patient exams per Group
• Groups rotate exam every 20 min
• Assemble at end for discussion
Vascular Physical Exam
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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
_____ _____ Common Femoral _____ _____ Popliteal
3. Bruit (yes, no)
right left_____ _____ Common Carotid
_____ Aorta _____ _____ Common Femoral
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 _____ _____ Ulceration _____ _____ Edema
Location
Examination Instrument
Vascular Physical Exam
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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
Vascular Physical Exam