PHYSICAL EXAMINATION

of the

VASCULAR SYSTEM
Hugh Gelabert, M.D. Vascular Surgery Division UCLA School of Medicine

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

Goal of Medical History

To record the patients 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 patients health at the time of the examination. To provide a longitudinal record of the patients health. Allow assessment of progression of disease. Allow prognostication of natural history. Allow recommendations for care.

Vascular Physical Exam

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

ARTERIAL ANATOMY

ARTERIAL ANATOMY

ARTERIAL ANATOMY

Vascular Physical Exam

Dorsalis Pedis
Posterior Tibialis

Vascular Physical Exam

Femoral Artery Popliteal Pulse

Vascular Physical Exam

Aortic Aneurysm Exam

Vascular Physical Exam

Subclavian Artery Exam

Vascular Physical Exam

Carotid Artery Exam

Vascular Physical 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 Physical Exam

Vascular Findings
Generally related to
Blockage of blood vessel Dilatation of blood vessel

Subsequent events
Ischemic tissue Gangrenous tissue

Vascular Physical Exam

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

Acute Ischemia
5 Ps
Pulseless Pain Pallor Paresthesia Paralysis Poikilothermia (Cold)

Acute Ischemia

Vascular Physical Exam

Acute Ischemia
An abrupt disruption of the normal blood supply to a vascular bed. Example:
Gunshot wound Fracture Tourniquette Embollus

Vascular Physical Exam

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

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

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

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. Raynauds) Acute Ischemia Chronic Ischemia

Vascular Physical Exam

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

Venous Guttering

Buergers test

Vascular Physical Exam

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

Vascular Physical Exam

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 distal painful sharp Art sx no pulse Venous maleolar +/irregular CVI sx OK pulse Neuro plantar no pain punched other Dx OK pulse

Location Symptoms Outline Assoc findings

What kind of ulcer ?

Neuropathic
Plantar location

Punched Out margins

Insensate

What kind of ulcer ?

Arterial Ulcer
Distal location

Sharp margins

Painful

What kind of ulcer ?

Venous Ulcer
Maleolar location

Irregular margins

Insensate or Painful

Ulcers
VENOUS

DIABETIC

ARTERIAL

Gangrene:
Necrosis or death of tissue.

Decubitus Eschar

Vascular Physical Exam

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 ischemic with acute necrosis, autolysis and liquefaction. In the absence of superinfection the tissue gradually dessicates and becomes mummyfied. Later, eschar separation and auto-amputation take place.

Blue Toe Syndrome

Digital Embolizationa

Vascular Physical Exam

Process of Auto Amputation

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

Auto-amputation

Vascular Physical Exam

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

Methods:
Discuss what you are about to do

inform patient of intention of examination explain how exam will be conducted

Vascular Physical Exam

Methods:
Prepare Yourself for the Exam approach exam systematically compare bilaterally review patient complaints as exam progresses

Vascular Physical Exam

Methods:
Follow Exam Sequence
observe auscultate lightly touch palpate compress

Vascular Physical Exam

Specific Observations
PULSES -- should note 17 pulses. -- quality (-, +, ++) Temporal Carotid Brachial Radial Aorta Femoral Popliteal Dorsalis Pedis Posterior Tibialis x2 x2 x2 x2 x1 x2 x2 x2 x2

Vascular Physical Exam

Specific Observations
ANEURYSMS -- should examine for 5 aneurysms Aorta x1 Femoral x2 Popliteal x2

Vascular Physical Exam

Specific Observations
BRUIT -- should listen for 5 bruit. Carotid x2 Aorta x1 Femoral x2

Vascular Physical Exam

Specific Observations

SIGNS OF ISCLEMIA -- look for 6 Ischemic Signs in each limb. Color Capillary Refill Eschar Temperature Ulceration Location

Vascular Physical Exam

Specific Observations
VENOUS SIGNS -- look for 5 Venous Signs in each limb Brawny Color Ulceration Location Varicose Veins Edema

Vascular Physical Exam

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

Vascular Physical Exam

Examination Instrument
Student Worksheet -- Specific Observations 1. Pulses -- should note quality (-, +, ++) right _____ _____ _____ _____ _____ _____ _____ _____ 2. Aneurysms (yes, no) right _____ _____ 3. Bruit (yes, no) right _____ _____ left _____ _____ _____ left _____ _____ _____ left _____ _____ _____ _____ _____ _____ _____ _____ _____ 4. Ischemic Signs -- signs of arterial disease. (normal, abnormal; yes, no; If yes, location) Superficial Temporal Common Carotid Brachial Radial Aorta Common Femoral Popliteal Dorsalis Pedis Posterior Tibialis 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

Aorta Common Femoral Popliteal

Common Carotid Aorta Common Femoral

Conclusion
Reviewed the Vascular exam Reviewed exam techniques Discussed common findings Discussed relation between patient symptoms and exam findings Next step Med West

Vascular Physical Exam

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

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

Examination Instrument
Student Worksheet -- Specific Observations 1. Pulses -- should note quality (-, +, ++) right _____ _____ _____ _____ _____ _____ _____ _____ 2. Aneurysms (yes, no) right _____ _____ 3. Bruit (yes, no) right _____ _____ left _____ _____ _____ left _____ _____ _____ left _____ _____ _____ _____ _____ _____ _____ _____ _____ 4. Ischemic Signs -- signs of arterial disease. (normal, abnormal; yes, no; If yes, location) Superficial Temporal Common Carotid Brachial Radial Aorta Common Femoral Popliteal Dorsalis Pedis Posterior Tibialis 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

Aorta Common Femoral Popliteal

Common Carotid Aorta Common Femoral

Vascular Physical Exam

Assessment 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: _____

_____