physical examination of the vascular system hugh gelabert, m.d. vascular surgery division ucla...

PHYSICAL EXAMINATIONof the

VASCULAR SYSTEM

Hugh Gelabert, M.D.

Vascular Surgery Division

UCLA School of Medicine

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

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.

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.

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

ARTERIAL ANATOMY

Posterior Tibialis

Dorsalis Pedis


Femoral Artery

Popliteal Pulse


Aortic Aneurysm Exam


Subclavian Artery Exam


Carotid Artery Exam


Bruit

• Sound made by vibrating arterial wall

• Caused by turbulent blood flow making arterial wall vibrate

• Indicates the presence of an arterial lesion


Vascular Findings

• Generally related to – Blockage of blood vessel – Dilatation of blood vessel

• Subsequent events– Ischemic tissue– Gangrenous tissue


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


Acute Ischemia

• 5 ‘P’s– Pulseless– Pain– Pallor– Paresthesia– Paralysis– Poikilothermia (Cold)


Acute Ischemia

Acute Ischemia

• An abrupt disruption of the normal blood supply to a vascular bed.

• Example: • Gunshot wound• Fracture• Tourniquette• Embollus


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 +


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.


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.


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


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


Tissue Refill

Buerger’s testVenous Guttering

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


Cyanosis with acute ischemia

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.


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

What kind of ulcer ?

Neuropathic

Plantar location

Punched Out margins

Insensate

Arterial Ulcer

Distal location

Sharp margins

Painful

Venous Ulcer

Maleolar location

Irregular margins

Insensate or Painful

Ulcers

DIABETIC

VENOUS

ARTERIAL

Decubitus Eschar

Gangrene: Necrosis or death of tissue.

Gangrene

• Death of tissue– Related to absent blood supply– Infections– Tissue Toxins– Radiation, Trauma

• WET Gangrene vs DRY Gangrene– Bacterial superinfection– Mumefaction or mumyfication


Wet Gangrene

Dry Gangrene

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.

Blue Toe Syndrome

Digital Embolizationa

Process of Auto Amputation

• Dry Gangrene of Digit– Tissue dessicates– Demaracation– Eschar separation– Epidermal ingrowth– Wound margin contraction– Osteolysis


Auto-amputation

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


Methods: Discuss what you are about to do

• inform patient of intention of examination

• explain how exam will be conducted


Methods: Prepare Yourself for the Exam

• approach exam systematically

• compare bilaterally

• review patient complaints as exam progresses


Methods: Follow Exam Sequence

• observe

• auscultate

• lightly touch

• palpate

• compress


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


ANEURYSMS

-- should examine for 5 aneurysms

Aorta x1

Femoral x2

Popliteal x2



BRUIT

-- should listen for 5 bruit.

Carotid x2

Aorta x1

Femoral x2



SIGNS OF ISCLEMIA

-- look for 6 Ischemic Signs in each limb.

Color Temperature

Capillary Refill Ulceration

Eschar Location




VENOUS SIGNS

-- look for 5 Venous Signs in each limb

Brawny Color Varicose Veins Ulceration Edema

Location


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


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.

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

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


Conclusion

• Reviewed the Vascular exam

• Reviewed exam techniques

• Discussed common findings

• Discussed relation between patient symptoms and exam findings

• Next step … Med West

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


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


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


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


physical examination of the vascular system hugh gelabert, m.d. vascular surgery division ucla...

Documents

goals of physical exam

exam findings

vascular findings

acute ischemia slide

vascular bed

exam techniques

arterial anatomy slide

physical examination