Vascular Exam and Evaluation • Rehabilitation goals

o Usually, pt centers their goal on their

By: Dave Matthew D. Fajardo, BSPT-3A lifestyle (e.g., runner wants to run
• It’s better to start with vascular conditions instead of cardio conditions again w/o pain in their foot)
because it’s overwhelming for most people. S- Pain / Discomfort
• It’s necessary to review the necessary structures to understand better
the condition as we go on with our practice. • Depends on the condition that they
have
Subjective • Venous insufficiency → ulcers
• Medical history • Quantify the type of pain that they feel
o Get this in a chronological way -> get better diagnosis & pt o Use VAPS
impression o Descriptors of the pain
• Medications (type/ dosage/ schedule)
o Anti-coagulants / anti-hypertensive
o Not the affect that we are looking at. But as pts, but how the
impact of the meds will affect the treatment.
o Note what type of meds, sched, and dosage
▪ Side effects can rlly affect interventions
• Diagnosis and hx of present condition
o Note: We can only give PTR if we have physiatrist or physician
approval d/t lack of direct access.
o In this case, diagnosis is already given.
• Current symptoms
• Results of any laboratory test
o Take into consideration: bacterial cultures → check for
infections
• Effects of any medial/ surgical interventions O - Basic Inspection
• Lifestyle (pre-morbid, daily, recreational, work)
o Marites mode – greater understanding of pt. lifestyle. 1. Texture – smooth & firm
o Ex: Vascular condition of the (L) foot, runner, - you can know 2. Size – changes in the nail bed (nail
what the goals of the pt are e.g., go back to running. clubbing – more convex (heart
o Smoking – comes out in every condition – cardiac, vascular, condition) – right picture
pulmonary 3. Position Alignment
4. Color
5. Tenderness – pain that the pt feels when palpation
6. Shape
O – Inspection of the Extremity Venous

 Based on picture • Wound base granulation

1. Size - okay • Wider and shallow
2. Symmetry - asymmetrical • Usually, superficial
3. Skin – • Irregular wound margins
a. Left – smooth & fair • More exudate (more fluid
b. Right - shiny & dry, dry scaling • Irregular appearance
on the right most area
4. Nail beds
a. Right: Discolored, w/ patches Note: Review on wound care (measuring ulcer, wound, depth of wound,
of red etc.). They are important in documentation. We also have to be aware if the
b. Left: Normal ulcer is expanding or or improving.
5. Color
a. Right:
b. Left:
6. Hair growth - no hair
7. Sensation - superficial assessment, pin prick, temp
8. Texture
9. Location – obvious deformities on the foot

O – Ulceration

Arterial

• Wound base pale

• Poor granulation
• Subcutaneous atrophy • Ulcers
• Small and deep o Common sites: over bony prominences
• Wound margins even o Color: red, brown, black or yellow
• Minimal exudate o Can be painful if sensation is intact
• Skin temp cool (lack of warmness of • Non-blanchable – redness is prevalent even if you press it (doesn’t go
blood away)
• Looks punched out
• Often painful
• Necrosis
 ▪ 1 to 1.5 cm = normal
▪ Beyond 1.5 = edema
▪ Less than 1 = atrophied muscle / hypotrophic
O – Palpation
• Pulses
o Axillary
o Brachial pulse in mid arm
o Radial pulse in distal forearm
o Brachial pulse in the cubital fossa
o Ulnar pulse in distal forearm
o Femoral pulse
o Popliteal pulse
o Posterior tibial pulse
o Dorsalis pedis pulse
 Assess pulse points near the affected the site and compare it w/
other sites
O – Swelling / Edema
• Rate –
• Also present in cardiac and • Rhythm -
pulmonary conditions • Strength –
• Identify if pitting or non- • This is something that we usually do not do (palpation of abdominal
pitting aorta
o Pitting – responds to
pressure
o Non- pitting – not
responds
• Swelling becomes more
evident as the day goes esp.
in afternoon due to the
prolonged standing
• Swelling can sometimes be
normal but some are caused
by underlying conditions.
• Can be done with LGM (Limb
Girth Measurement) – picture
on the right
o Review PoE Lab for this
o Difference:
O – Auscultation • Take note at the angle at w/c the limbs become pale
• Sit the pt up & ask them to hang their legs down over the side of the
Bruits
bed
• Auscultation for abdominal bruits is the next phase of abdominal
examination.
• Bruits are "swishing" sounds heard over major arteries during systole or,
less commonly, systole and diastole.
• The area over the aorta, both renal arteries. and the iliac arteries should
be examined carefully for bruits.

Note: Elevating a limb, especially the legs, above the heart allows the blood
to circulate back to the heart without fighting gravity. The heart still pumps
blood to these extremities, but the stress on the heart is reduced. This helps
to mitigate swelling and brings fresh and oxygenated blood to the limbs.

Venous Filling Time:

• Assess arterial flow by

evaluating time veins take
to fill after emptying
Sensory Assessment • The same process with
arterial insufficiency but this
• Basic – pin prick, light touch, time we are looking at the
• Take time to assess sensation of affected structures veins if they pop up (see
below pic)
• The extremity is elevated
Buerger’s Test for 1 min at 60 deg and then
• W/ the pt positioned supine, stand at the bottom of the bed (PT) & raise lowered into a dependent
both of the pt’s feet to 45 deg for 1-2 mins position
• Observe the colour of the limbs: • The time it takes for the
o The development of pallor indicates that peripheral arterial veins on top of the foot to refill is recorded
pressure is unable to overcome the effects of gravity, o Normal filling time is 15 secs
resulting in loss of limb perfusion o > 15 secs indicates arterial disease
 o whereas, < 15 secs indicates venous disease
• Capillary Refill Test
o Normal if the original color comes back in less than 2
seconds
• Schamroth sign
o If 2 opposing fingers are held back to back against each
other, a diamond-shaped space should normally appear
between the nail beds and the nails of the 2 fingers.
o In clubbing, this space (or window) is missing
o associated with pulmonary and cardiovascular diseases
Homan’s Test
• Pt is supine
• Examiner lifts the affected and leg & rapidly dorsiflexes the pt’s foot w/
the knee extended.
• This maneuver is repeated with the pt’s knee
flexed while the examiner simultaneously
palpates the calf
• Homan’s sign is positive if pain is occurring
upon dorsiflexion of the foot w/ the knee
extended and flexed indicating deep vein
thrombosis (DVT)
• Not really the 1st test to use to rule out DVT.
Can sometimes give off a false positive
o Possibly that the calf is inflamed (from strenuous activity) or
tight calves/ gastric

Trendelenburg test for Venous Insufficiency

• Measures the time required to refill the veins in the dorsum of the foot
• The LE is elevated to allow venous blood to empty. A tourniquet on the
thigh prevents backflow. After a minute, the individual stands
o If veins fully distend within 5 secs before the tourniquet is
Percussion Test
released, valvular incompetence in the deep veins is
• With LE in a dependent position, the greater saphenous vein is palpated suspected.
distal to the knee w/ one hand o If distention occurs within 5 seconds after the tourniquet is
while it is tapped 6 in (15. 2 cm) released, incompetence of superficial veins is suspected
proximal to the knee w/ the other
hand.
o If a wave of fluid is
detected under the
distal palpation site,
this indicates the
possibility of valvular
incompetence.
Doppler Ultrasound

• A Doppler ultrasound test uses reflected sound waves to see how blood
1. Locate Pedal Pulse
flows through a blood vessel. It helps doctors assess the blood flow
2. Attach the cuff to the ankle
through major arteries and veins, e.g., as those of the arms, legs, and
3. Apply US gel to the pulse point
neck.
4. Apply the transducer head on the pulse point and allow to establish
• The test also can find blood clots in leg veins (DVT) that could break the sound of the pulse
loose & block blood flow to the lungs 5. Inflate cuff until pulse sound is eliminate
Ankle Brachial Index 6. Slowly release the pressure in cuff and note the mmhg reading
where the first return of sound is heard.
• A quantifiable measurement of lower leg blood supply 7. Repeat procedure with the Posterior Tibial pulse
• A comparison of the systolic pressure in the upper arm to the systolic 8. Choose the higher mmhg value between the two
pressure at the ankle 9. This will be your Systolic Ankle.
• The ankle pressure should be equal to or slightly higher than the arm in
the absence of arterial occlusive disease.

Materials:

• Blood pressure sleeve or cuff

• Doppler Pulse Machine

Procedures:

1. Locate brachial pulse

2. Attach the cuff
3. Apply US gel to the pulse
point
4. Apply the transducer head
on the pulse point and
allow to establish the
sound of the pulse
5. Inflate cuff until pulse
sound is eliminate
6. Slowly release the pressure
in cuff and note the mmhg
reading where the 1st
return of sound is heard
7. This will be your Systolic Brachial BP
• If they are high of risk developing pressure ulcers, we must employ
interventions such letting pt change position often

Transcutaneous Oxygen

• A noninvasive examination tool for arterial circulation

• A special probe and a heating element measure profusion.
Measurement of oxygen at the skin level gives information about what
is happening at the cellular level. Also found in the literature as
transcutaneous partial pressure of oxygen and transcutaneous oxygen
tension measurement.
o The results are predictive for healing of ulcers and
amputation wounds.

Air Plethysmography

• A noninvasive test of both the arterial and venous circulation

• Changes in LE volume are measured using a pressure cuff that quantifies
volume changes during rest, standing, and light walking.
o Venous obstruction and arterial inflow can be observed
with his test.