Peripheral vascular exam-2

Question 1

What is the overall approach to the peripheral vascular exam?

Answer 1

Inspection of the lower limbs

Describe the differences of arterial and venous insufficiencies

Palpate for temperature, capillary refill, edema

Measure calf circumfrence

Identify palpation point of peripheral ateries

Identify features of arterial and brachial pulses

Identify and describe symmetry and amplitude of pulses

Radial femoral delay

Correct technique for peripheral palpable blood pressure and ausculatory blood pressure

Pulsus paradoxus

Auscultate the peripheral arteries (BRUITS?)

Sapheneous vein anatomy

Special tests

Question 2

What does inspection of the lower limbs include?

Answer 2

Colour (pallor, cyanosis, rubor (red), brown (hemosiderin)

Hair distrobution–> often decreased hair on lateral aspect of legs in arterial insuficiency

Skin thickness

Ulcerations

• in arterial insuficiency ulcers on toes and heels
• in venous insuficiency ulcers on medial maleoli

Varicosities

Edema

Scars

Muscle wasting

In between toes–> fungal infection and broken down skin

Nail growth and appearance

Question 3

Compare and contrast venous from arterial insufficiency

Answer 3

Question 4

What do you palpate for in peripheral vascular exam?

Answer 4

Temperature–> back of hand down both legs simultaneously

Capillary refill time–>press on nail until it turns white, release and watch how long it takes to return to normal colour–> > 3 seconds is abnormal

Assess for edema

pitting edema-

non pitting edema-usually associated with lymphedema

edema goes to the lowest place–> check the coccyx on bed ridden patient

Question 5

What are the features of measuring calf circumfrence?

Answer 5

Measure the same distance below the tibial tuberosites on both legs

up to 2cm in difference between calfs can be normal

only 1cm in ankle difference is allowed

Question 6

Palpation of arteries

Answer 6

Radial artery

Brachial artery

Abdominal aorta–> use fingers to approximate width ~1inch)

Femoral–> mid inguinal point, lateral corner of pubic triangle

Popliteal –> both thumbs on same tibail tuberosity, all eight fingers dig into lateral part of back of knee

Dorsalis pedis

Posterior tibial–> behind and below the medial malleolus

Question 7

What particular do you comment on about the radial and brachial arteries?

Answer 7

Rate–> bradycardia or tachycarida

Rhythm–> regular, regular irregular or irregularly irregular

Symmetry–>Symmetry (both sides)

Amplitude–>absent, decreased, normal, increased, bounding

Contour–>Describe wave form

Question 8

How do you assess for radial femoral delay?

Answer 8

Femoral pulse usually occurs before radial

radial femoral delay happens when the blood flow to the descending aorta depends on collateral vessels

–> coarcation

–> aneurysm

if radial artery pulse if found before the femoral pulse then this is positive

Question 9

How is ascultation used in the peripheral vascular exam?

Answer 9

1)Ausculatory blood pressure

2)Pulsus paradoxus–> the difference between the expiratory and inspiratory blood pressure

• set up patient for ausculatory blood pressure normally
• inflate cuff until no sounds are heard
• Deflate cuff until sounds are only heard durring expiration –> note pressure
• Deflate cuff until sounda re heard durring expiration and inspiration

pulsus paradoxis> 10 is abnormal

3)Ascultate the following arteries commenting on bruits

a) brachial
b) abdominal (midline above umbilicus)
c) renal (5cm above umbilicus and 3-5 cm on either side of midline)
d) iliac (3-5 cm midline just below umbilicus)

Question 10

What are the special tests in the peripheral vascular exam?

Answer 10

1)Allens test

• patient to make tight fist and then elevate above head to drain blood out
• occlude radial and ulnar arteries
• lower patients hand
• ask patient to open hand (plm should be pale)
• release pressure on either the radial or ulnar atery
• should redden within 5 seconds
• compare time to refil holding either of the two arteries

the slower artery is occluded

if both are equally slow (> 5 sec), then proximal occlusion

if no redening after releasing ulnar artery–> no connection between deep and superficial arches

2) straight leg raise and refill test

• patient supine
• raise both legs to 45 to 60 degrees for 30 seconds or until pallor in feet devlop
• patient sits up and danlges feet on side of table
• pink colour should come back in 10 seconds (> 10 seconds = arterial insufficiency)
• dusky colour = arterial insufficiency

3)incompitent sapheneous vein test (test for venous insufficiency)

identify saphenous vein

compress vein with one finger

place other hand 15-20cm above other vein

tap vein

–> look for transmitted vibrations to distal hand