Peripheral Vascular Exam Flashcards
Peripheral Vascular System
Consists of a system of interconnected veins and arteries which carry blood to and from the heart & lungs
Also involves the capillaries and lymphatic system
3 Arterial Pulses in the Upper Extremity
- Brachial– antecubital fossa
- Radial
- Ulnar
4 Abdominal Arteries
- Aorta
- Renal
- Iliac
- Mesenteric
Upper Extremity Veins (7)
Cephalic Subclavian Internal Jugular radial ulnar basilic SVC
Four pulses of the Lower Extremity
Femoral
Popliteal
Posterior Tibial
Dorsalis Pedis– 1st and 2nd
metatarsals2 systems of lower extremity veins
Superficial
- Great Saphenous - Small Saphenous 2. Deep - Femoral - Popliteal
2 Lymph Nodes in the Upper Extremity
- Epitrochlear Node - 3 cm above medial epicondyle
of the elbow - Axillary Nodes - multiple in axilla
2 Lymph nodes in the lower extremity
- Horizontal Superficial Inguinal Nodes - lies in a
chain in the proximal anterior thigh just below the
inguinal ligament - Vertical Superficial Inguinal Nodes – lies in a cluster
in the upper part of the Saphenous vein
Risk factors of peripheral vascular diseases
- Tobacco use
- Alcohol abuse
- Cocaine use
- F/H of PAD/CAD/CVD/DVT/PE
- Obesity (BMI > 30)
- Age > 50 y/o
- Recent long distance travel
- Prolonged Inactivity
- Pregnancy or Post Partum
- Malignancy
Arterial Manifestations for peripheral vascular diseases
- Diminished or absent pulses
- Smooth, shiny, dry skin
- Loss of hair on lower extremities
- No edema
- Round, regular shaped painful ulcers on distal foot,
toes, or webs of toes - Dependent rubor– red color/tinge to the leg
- Pallor or pain when legs elevated
- Intermittent claudication- pain/ cramps ppl get
- Brittle thick nails
acute symptoms of arterial compromise
- Sudden Pain
2. Pulselessness
3. Pallor
4. Paraesthesias (numbness)
5. Paralysis (sudden weakness)
Chronic Symptoms of arterial compromise
a. Intermittent Claudication
b. Rest Pain
c. Tissue loss
1. Peripheral = Ulcer
2. Cerebral = TIA/CVA
3. Visceral = Mesenteric Ischemia or Bowel Infarction
4 characteristics of arterial problems
- Arterial Circulatory Compromise (Most Common)
a. Acute = Embolus
b. Chronic = Thrombosis
c. Compression = Positional/Postural - Bleeding = Rupture of an Aneurysm or Trauma
- Spasm = Raynaud’s Disease
- Inflammation = Arteritis
Different locations of obstruction
Aorto-iliac Disease = Gluteal Claudication
Femoral-Popliteal = Leg/Calf Claudication
Axillary Embolus = Ischemic changes in the forearm & hand
Brachial Embolus = Ischemic changes in the fingers & hand
DVT = Painful, swollen unilateral arm or leg
Arterial Causes of peripheral vascular disease
- Atherosclerosis (Thrombosis, Embolic)
- Diabetes
- Vasospastic Disorders (Raynaud’s)
- Trauma
Venous Manefestations
- Normal pulses
- Brown patches of skin discoloration on lower legs
- Dependent edema
- Irregular shaped, usually painless ulcers on lower
legs and ankles - Dependent cyanosis and pain
- Pain relieved with legs elevated
- No intermittent claudication
- Normal nails
Venous Causes
- DVT/PE
- Varicosities
- Venous Stasis Disease
JVP Exam
- Elevate head of bed to 30 to 45 degrees
- Look for increased JVP
- Measure JVP from the right (7 cm or > abnormal)
Upper Extremity Inspection
- Inspect both arms from the fingertips to the
shoulders and note:
- Size, Symmetry, or any Swelling
- Venous pattern
- Color of nail beds
- Capillary Refill (< 2 sec)
- Lesions or ScarsLower Extremity Inspection
- Inspect legs from groin to toes bilaterally and note:
- Size, Symmetry, and any Swelling
- Venous pattern & any venous enlargement or
varicosities - Pigmentation, Scars, Ulcers or Rashes
- Color of Nail Beds
- Hair distribution on the legs, feet, & toes
- Muscle atrophy
- Loss of toes
- Obvious Pulsatile Masses (ant=femoral aneurysm,
post=popliteal aneurysm
Pulse Grading
- Grading
0 = Absent
1+ = Diminished
2+ = Normal
3+ = Increased
4+ = Bounding (may occur with hyperthyroid, fever,
exercise, anxiety)Characteristics of Pulses
Rate
Rhythm
Tortuosity
Tenderness
Bruits (Thrill)Palpations and Auscultation of the Head & Neck
- Palpation: (Bilateral)
- Temporal Pulse (Pain = ? Temporal arteritis)
- Carotid Pulse (Auscultate for bruit first)
- Auscultation: (using bell bilateral) - Temporal Artery for Bruits (Temporal Arteritis)
- Carotid for Bruits at 3 points (Base, Mid, & at angle
of Mandible) - Supraclavicular & Infraclavicular for Subclavian
bruits
Upper Extremity Palpation
- Skin turgor, texture, & temperature
- Brachial, Radial, & Ulnar pulses
- Epitrochlear lymph node (size, consistency,
mobility, & tenderness)
Auscultation of the Upper Extremity
- Measure BP using Brachial Artery bilaterally normal
is 120/80 per JNC7 criteria
a. Change in BP > 20 mmHg Systolic & 10 mmHg
diastolic from arm to arm is abnormal
b. Orthostatic Hypotension
c. Pulsus Paradoxus
Pulsus Paradoxus
is a decrease in BP > 10 mmHg
during inspiration and may indicate several
conditions including Cardiac Tamponade, Pericarditis,
COPD, Chronic Sleep Apnea, & Croup
Orthostatic Hypotension
is a decrease in systolic
BP > 10 mmHg & increase in heart rate > 10 bpm
with change of position from lying flat to sitting &
then to standing indicates hypovolemia
Allen’s Test
for patency of radial & ulnar arteries
prior to A-line insertion or use of Radial A. in CABG
or for Cardiac Cath canulation
Adson’s Test and Wright’s Maneuver
Test for Thoracic
Outlet Syndrome with complaints of pain or
numbness in arms from compression of
Subclavian A. between clavicle & 1st rib
Palpation of Lower Extremity
- Skin turgor, temperature, & texture
- Muscle Tone
- Proprioception of toes (early sign of acute arterial
ischemia) - Capillary Refill (< 2 sec. is normal)
- Femoral Pulse
- Inguinal Lymph Nodes
- Popliteal Pulse
- Posterior Tibialis Pulse
- Dorsalis Pedis Pulse
Auscultation of Lower Extremity
- Femoral for bruits with bell
- Use of doppler will help determine flow in others
a. Biphasic = normal
b. Monophasic or Absent = abnormal
- Use of doppler will help determine flow in others
Ankle Brachial Index
measures systolic BP in
Brachial A. and compares with Posterior Tibial A. &
Dorsalis Pedis A. using a doppler
Index
1 – 1.2 normal
< 0.9 mild to moderate PAD
< 0.4 severe PAD
> 1.3 non-compressible (DM & Chronic RF)
Other Tests that can be used for arterial Peripheral Vascular Disease
- PVR & segmental limb pressures
- Ultrasound
- MRA– no radiation
- CT Angiography
- Conventional Angiography
Palpation of abdominal aorta
- Aorta – just above umbilicus with patient supine,
try to find the edges normal width approx. 3 cm if
greater may indicate AAA
3 Systems of the venous system
- Superficial
- Deep
- Perforating – connects superficial to deep
All 3 systems have one way bicuspid valves that permit flow from superficial to deep & distal to proximal
3 functions of the venous system
- Return deoxygenated blood to the heart
- Storage – contains 70% of total blood volume
- Thermoregulation
- Regulation of Cardiac Output
Venous System Problems
Valvular Dysfunction – varicosities
Deep Venous Obstruction – DVT/PE
Chronic Venous Insufficiency – chronic DVT & post phlebitic syndrome
Superficial Vein Inflammation or Infection – superficial phlebitis
Inspection of the Venous System PE
in supine & standing positions
- Unilateral/Bilateral extremity edema
- Dyspnea
- Presence of Varicosities
- Pain/Discomfort/Cyanosis of extremities
- Skin tension
- Hyperpigmentation of lower leg
- Ulcers
- Pallor with patchy cyanotic or gangrenous areas
- Presence of skin bullae or vesicles
- Prominent & dilated veins on chest wall & neck
along with facial edema = SVC obstruction
Palpation of LE
- Tenderness
- Increased skin temp
- Edema – pitting vs non-pitting
- Measure circumference of calf at the same point on
both sides 10 cm distal to tibial tubercle - Induration
- Pulses of extremities
Special Tests of the Venous System
- Venous Duplex Doppler to r/o DVT
- D-Dimer controversial use based on PERC criteria
- Chest Spiral CT to r/o PE
