PHYSICAL EXAMINATION of the VASCULAR SYSTEM Hugh Gelabert, M.D. Vascular Surgery

PHYSICAL EXAMINATION of the VASCULAR SYSTEM Hugh Gelabert, M.D. Vascular Surgery www.phwiki.com

PHYSICAL EXAMINATION of the VASCULAR SYSTEM Hugh Gelabert, M.D. Vascular Surgery

Lawrence, James, Contributing Editor has reference to this Academic Journal, PHwiki organized this Journal PHYSICAL EXAMINATION of 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 in addition to 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 in addition to direction as long as 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 as long as care. Arterial Anatomy Goals establish presence in addition to quality of pulses establish presence or absence of findings: aneurysms, arterial bruit, signs of ischemia, signs of venous disease Vascular Physical Exam ARTERIAL ANATOMY

ARTERIAL ANATOMY ARTERIAL ANATOMY Posterior Tibialis Dorsalis Pedis 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 ‘P’s Pulseless Pain Pallor Paresthesia Paralysis Poikilothermia (Cold) Vascular Physical Exam Acute Ischemia

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 in addition to Bone + Vascular Physical Exam Chronic Ischemia A process where the gradual onset in addition to magnitude of ischemia has allowed the body time to compensate as long as 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 gl in addition to s Lost Result: Thin, dry, skin with loss of hair, abnormal nail growth / fungal infections. Vascular Physical Exam Capillary Refill The time required as long as 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 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 test Venous 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 in addition to will not blanch on palpation Vascular Physical Exam Cyanosis with acute ischemia

Ulceration A discontinuity in the integrity of the skin which persists despite sufficient time as long as healing. Must be able to distinguish three types: Arterial, Venous, Neuropathic. Vascular Physical Exam 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

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 as long as discussion Vascular Physical Exam 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 Did the student examine in addition to 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 as long as aortic aneurysm between umbilicus in addition to xyphoid — — palpate as long as popliteal pulse or aneurysm with two h in addition to s — — st in addition to at foot of patient while palpating dorsalis pedis in addition to posterior tibial — — compress ankle to assess edema — — feel toes to asses temperature — — press toes to asses refill Totals: — — Assessment Instrument Vascular Physical Exam

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