CLINICAL 4: pulses and vascular exam Flashcards
What are all the different pulses examined in the peripheral vascular exam?
Radial
Carotid
Femoral
Tibial
What should be looked for in the general inspection of the peripheral vascular exam?
Patient should remove t -shirt and be exposed from knee down preferably
Signs of bypass
Cyanosis
Pallor
Amputation
What should be looked at int he hands in the peripheral vascular exam?
Assess the colour of fingers and nails, look for tar staining and venous filling.
Look at the palm and dorsal surface of the hands
Check capillary refill time
Check the peripheral temperatures, work up arm comparing in both sides using the back of your hand
Check the radial pulse in one arm (rhythm, rate and volume)
Compare to the radial pulse in the other arm (are they synchronised radio-radial delay indicates aortic coarctation)
Palpate coth brachial pulses
Record blood pressure in both arms.
What should be looked at in the neck during the peripheral vascular examination?
The carotid pulse (both sides)
Auscultate the carotid arteries
What should be done in the abdominal area of the patient for the peripheral vascular examination?
Inspect for pulsatile mass or scars
Palpate the abdominal aorta
Listen for abdominal bruit
Feel the the femoral pulse (both sides), half way between AIIS and pubic symphysis in the groin region
Listen for femoral bruis on both sides
What should be done in the lower limb for the peripheral vascular examination?
Examine the feet and legs for ulcers, scars, hair loss and pallor.
Ask the patient to lift up the legs to look underneath for ulcers
Examine between the toes for ulcers
Ask to wiggle toes - loss of motor indicates ischemia
Capillary refill time of the big toe
Assess temperature comparing the left and right side using the back of your hand
Popliteal pulse - support weight of the leg and listen for bruis
Tibial pulse - both sides
Dorsal pedis pulse - both sides
Assess light touch - if patient can tell if touching right or left foot (test inside and outside)
What should be done to complete a peripheral vascular exam?
Buergers test if indicated
Request an Ankle Brachial Pressure Index
Full cardiovascular examination
What is Buergers test?
Assessment of arterial sufficiency to the leg.
Completes in two stages
Check for hip pain before proceeding with the test.
What is stage 1 of buergers test?
Patient in supin position
Elevate legs in 10-15 degree stages to a maximal angle of 90 degrees
Observe colour of toes and soles as progress
The vascular angle is the angle they become pale (when peripheral arterial pressure is inadequate to overcome the effects of gravity)
Poorer supply - lower angle
Less than 20 - severe ischemia
less than 30 - ischaemic leg
What is stage 2 of the buergers test?
Sit patient up and swing legs over side of bed
Gravity aids blood flow and colour return
Foot first becomes blue as blood returns but is deoxygenated in its passage through ischaemic tissue
Becomes red due to reactive hyperaemia and post hypoxic vasodilation
What should be looked for in the general inspection in the peripheral venous exam?
Obesity and pregnancy
What should be done in the lower limb for the peripheral venous examination?
Inspect all side - spider veins, varicose veins, pitting odema, haemosiderin deposition, venous ulcer (gaiter area), atrophy blanche, lipodermatosclerosis.
Palpate -saphena varinx at saphenofemoral junction
Great saphenous and small saphenous vein on each leg for varicosities, thrombophlebitis, scar tissue
Assess temperature and any venous swelling
Ausculatate varicosities for bruits
What are the special tests that should be done in a peripheral venous exam?
Tap test
Trendelenburg (tourniquet) Test
Perthes Test
What is the tap test?
Press one finger at the saphenofemoral junction or saphenopopliteal junction proximal to the varicosisy of interest
Tap the distal varicose vein and a thrill should be transmitted up to the junction.
What is trendelenburg/tourniquet test?
Raise affected leg and milk to encourage veins to empty
Around the upper thigh apply a tourniquet to tightly constrict the saphenous vein
Femoral vein blood flow will not be affected
Ask patient to stand and note the degree of filling of the saphenous vein.
negative result - fill within 30 seconds - normal
positive result - remain collapsed throughout 30 second period and will only fill once tourniquet is removed
What is perthes test?
Used for peripheral venous exam
TIgh tourniquet around upper thigh
Ask patient to stand -
Ask patient to stand up and down on their toes a few times
Veins become less tense/ less varioceled if veins are competent.
Tests for deep venous sufficiency
What further tests should be requested after a peripheral venous examination?
A doppler ultrasound
A venous duplex scanning
Peripheral arterial examination
