8. Peripheral Vascular Exam Flashcards
What are the only palpable lymph nodes?
What would you examine in the initial general part of the peripheral vascular examination for the arms and legs?
Cervical, supraclavicular, axillary, arm and leg LN.
Arms: size, symmetry, temp, colour, oedema, radial and brachial pulse, epitrochlear LN, Allen’s test (radial and ulnar patency), venous filing
Legs: size, symmetry, temp, colour, femoral pulse, bruit and inguinal LN, popliteal, DP and PT pulse, peripheral oedema, ulcers/lesions
Would also look at abdomen
What foot/ankle pressure areas would you inspect?
What would you include in palpation?
What upper limb and lower limb pulses would you check?
Lateral side of foot, head of first metatarsal, heel, both malleoli, tips of toes. Look between each toe. [Pic - top L = diabetic foot ulcer, bottom R = collapsed foot - Charcot foot]
Run back of hand down both limbs (compare), cap refill, elevation (pallor/guttering/Buergers - infalmmation and thromboses of small/medium arteries/veins of hands/feet), pulses
Upper limb: subclavian, carotid, brachial, radial(compare pulses in both), ulnar, cap refill
Lower limb: aorta (push in as they exhale), femoral (mid-inguinal), popliteal (hard to feel), posterior tibial, dorsalis pedis, anterior tibial
What is Allen’s test?
What arteries would you auscultate in the vascular exam?
How might you grade the amplitude of arterial pulses?
How would you palpate for the subclavian artery?
Hand elevated. Clench fist for 30s, occlude both radial and ulnar arteries, pt opens elevated hand rapidly. Palm of hand should be pale. Remove finger from ulnar artery. colour should return in 5-15s.
To listen for bruits. Over aorta, iliacs and femoral, subclavian and carotid arteries. Measure BP
2 = increased, 1 = normal, 0 = absent
Palpate in root of posterior triangle [Pic]
What pathology might you notice if you elevated a leg to 15o?
If you elevated further, what is the point called at which the leg turns pale?
The patient is then asked to hang their legs over the edge of the bed. What is this test called and what are you looking for?
What would you do to ‘complete your arterial peripheral vasculature exam’?
Venous guttering
Buerger’s angle (<20o indicates severe ischaemia)
Buerger’s test - white -> pink -> flushed purple-red = reactive hyperaemia. Indicative of more severe disease. Both legs examined simultaneously so more obvious when one has less than adequate circulation
Examine the rest of the peripheral vascular system including the cardiovacular system, test relevant muscles and nerves of affected limb, perform ABPI (ankle-brachial pressure index: the higher of 2 BP from dorsalis pedis/anterior brachial is numerator, brachial BP is denominator. Usually within 10mmHg of each other if no stenosis etc. Peripheral arterial disease is ABPI < 0.95)
What would you inspect in the venous peripheral vasculature exam?
What are some signs of venous hypertension?
What would you do/look for in venous palpation?
General. Scars, swelling, veins (distribution, size, extent - varicose veins, venous stars - minute veins radiating from a single feeding vein). Skin - esp. lower and medial third, affected first, pigmetation, eczema and ulceration. Signs of venous HTN
Swelling, eczema, hemosiderin deposition, lipodermatosclerosis [pic - far R], ulceration.
Pitting oedema, subcutaneous tissues (thick/tender?), vein (compressible, tenderness, temperature), cough impulses (over saphenofemoral and saphenopopliteal junctions e.g. hold fingers over standing pt’s saphenofemoral opening (5cm below and medial to femoral pulse), pt coughs, if vein incompetent, feel fluid thrill). Venous duplex scan better
Describe the following tests (for palpation, venous part of exam):
a) Trendelenburg test
b) Torniquet test
c) Tap
d) Perthe’
a) Pt lies down and lifts leg to empty veins. Place 2 fingers over saphenofemoral junction, ask pt to stand. If veins remain empty while standing, junction is incompetent. Release pressure at junction to see. Unreliable test - perform Doppler test as alturnative.
b) Pt supine with leg elevated, sweep veins empty, note how easily they empty, of fail to empty = high pressure in them, look for signs of occlusion/compression. Place tourniquet around upper 1/3 thigh to occlude superficial veins. Stand pt.
If veins above tourniquet distended saphenofemoral junction incompetent.
If veins below tourniquet fill there must be a perforator below tourniquet so elevate leg and repreat proceedure with tourniquet at lower position on leg
c) Finger over SFJ, tap VV’s lower down leg, if they are in continuity will feel thrill
d) Determines competency of deep femoral veins, apply tourniquet mid-thigh, walk/flat/tip-toe for 5 mins, if competent blood returns to heart with no symptoms. If incompetent symptoms increase and VVs enlarge
What might venous clusters represent?
What would you do to ‘complete your venous peripheral vasculature exam’?
AV fistula.
Examine abdomen (why are the veins not bringing blood back?), perform DRE, pelvic examination/examine external genitalia (varicoele etc.)
