Peripheral Vascular Exam

Question 1

Equipment for peripheral vascular exam

Answer 1

Stethoscope (bruits)
2 rulers and pencil to assess JVP (15 cm long at least)
Penlight (JVD)
Pape measure (calf circumference for JVT)

Question 2

External clues to circulatory status

Answer 2

Hair pattern on extremities
Skin color (cyanosis, rubor, pallor, mottling)
Capillary refill time
Temperature of skin
Pulse strength and regularity
Dependent edema

Question 3

Sequence of blood flow through the systemic circulatory system

Answer 3

See pictures
Pulmonary circulation: Deoxy blood enters SVC & IVC-RA-RV-PA-Lungs
Systemic circulation: oxygenated blood enters heart from PV-LA-LV-Aorta-System (Head and Body)!

Question 4

Characteristics of arterial pulse and pressure and describe the steps in examination

Answer 4

Arterial pulse: ventricular systole (pressure wave) through arterial system - examining of pulse = carotid
Arterial Pressure: force restarted by blood against wall of artery - from blood exiting left ventricle during contraction
Checking for: stroke volume, ability aorta/larger arteries to distend, obstructed blood flow, peripheral artery resistance, viscosity of blood

Question 5

Jugular Venous Distention

Answer 5

dissension of external jugular veins, suggests poor right heart function (in athletes may be due to musculature)

Question 6

JVD exam and interpretation

Answer 6

Tangential light, look at level above clavicle (3-4cm at 45 degree angle could be indication of vascular disease)

Question 7

Jugular Venous Pressure

Answer 7

A means of estimating right atrial pressure. Venous pressure will rise when right heart fails and is unable to successfully empty

Question 8

Hepatojugular reflux

Answer 8

dissension of neck veins precipitating the maneuver of firm pressure over the liver. Tricuspid regurgitation, heart failure (non valvular), constrictive pericarditis, cardia tamponade, and IVC obstruction.

Question 9

Carotid pulse

Answer 9

Location: Just below jaw angle

Question 10

Brachial pulse

Answer 10

Location: Medial antecubital fossa of elbow

Question 11

Radial pulse

Answer 11

Location: thumb side of wrist

Question 12

Ulnar pulse

Answer 12

Location: pinky side of wrist

Question 13

Abdominal aorta

Answer 13

Location: left lateral and superior to umbilicus

Auscultate before palpating, use both hands measure width (2.5cm)

Question 14

Femoral

Answer 14

Location: Groin crease

Question 15

Popliteal

Answer 15

Location: directly behind knee (flexed)

Question 16

Dorsalis pedis

Answer 16

Location: top of food, btw metatarsals 1 and 2

Question 17

Posterior tibialis

Answer 17

Location: posterior to medial malleolus of ankle

Question 18

Amplitude of pulse, rating scale

Answer 18

0= no palpable pulse
1+ = diminished
2+ = normal/expected
3+ = full/increased
4+ = bounding

Question 19

Pulsus alternans

Answer 19

Pulse has constant rate and rhythm but amplitude (force) alternates between a smaller amplitude and larger amplitude
*Can be due to left ventricular dysfunction

Question 20

Pulsus bigeminus

Answer 20

Normal pulse beat followed by a premature beat (due to premature ventricular contraction) and a pause.
*Can be due to heart disease, digitalis toxicity, or a temporary benign finding

Question 21

Pulsus bisferiens

Answer 21

Pulse has two peaks during systole: the first is the ‘normal’ pulse that occurs during ventricular contraction, but the second is an early diastole due to a back flow of blood; best noticed with palpation of carotid artery.
*Can be due to severe aortic regurgitation or aortic stenosis coupled with aortic insufficiency

Question 22

Pulsus paradoxous

Answer 22

Atypical decrease in systolic arterial BP (>10mmHg) and amplitude during inspiration. Normally there is a slight decrease in BP with inspiration, but less than 10 = abnormal. Detected by taking BP (difficult to detect with palpation)
*Can be due to emphysema, asthma, premature heart contraction, tracheobronchal obstruction, pericardial effusion

Question 23

Pulsus deficit

Answer 23

Difference between the rates in pulse when auscultating the heart’s apex vs. palpating a peripheral artery
*Occurs when ventricular contraction doesn’t eject a sufficient amount of blood to produce a pulse wave in the arteries. Often associated with premature beats, pulses bigeminus, and atrial fib.

Question 24

Locations to assess for bruits

Answer 24

turbulent blood flow though the corresponding artery.
May indicate murmur, stenosis, aneurysm, etc.
Locations: Carotid, subclavian, abdominal aorta, renal, iliac, and femoral arteries.

Question 25

Venous insufficiency | chronic

Answer 25

History of phlebitis, leg injury, chronic stasis | *manifests with brawny ankle edema and induration, stasis pigmentation, varicosities ankle ulcerations

Question 26

Venous Obstruction

Answer 26

Acute Superficial Thrombophlebitis: Partial or complete occlusion of vein by thrombus w/secondary inflammatory reaction causing scarring of vascular wall **Tender, swollen, erythematous area overlying superficial vein May be from mild injury. DVT: pain and swelling in ankle, calf or thigh associated with blood blot - may progress to pulmonary embolism, Homan's sign Calf measurement: >1cm difference

Question 27

Arterial insufficiency | chronic

Answer 27

Inadequate arterial circulation *May be manifested by pain, intermittent claudication, rest pain, absent or diminished pulses, pallor on elevation, rubor on dependency, ulcerations, coldness, gangrene

Question 28

Arterial Obstruction

Answer 28

EMERGENCY! *manifests as pain numbness, tingling, weakness, pallor, mottling, superficial vasculature collapse Distal pulses are absent (Allen test) Associated with atherosclerotic disease

Question 29

Varicosities

Answer 29

Dilated, tortuous alterations in the saphenous veins and tributaries *dull, aching pain and heaviness Hereditary and exacerbated by pregnancy and obesity

Question 30

Dependent edema/ pitting and non-pitting

Answer 30

Press firmly over bony prominence comparing like areas and recording surface topographic references

Question 31

Claudication

Answer 31

History of pain caused by too little blood flow during exercise (cramping) Generally affects the blood vessels in the legs, can affect arms Symptom of peripheral vascular disease

Question 32

Capillary refill

Answer 32

Greater than 2 seconds indicates arterial insufficiency

Question 33

JVP exam and interpretation

Answer 33

Observe R internal jugular vein for flutter (different from carotid, and not true pulse), tangential lighting, patient is at 30-45 degree angle, place ruler vertical (tip an sternal angle), place straight edge horizontally at top of visible JVP pulsations (create 90 degree angle) Measure distance from sternal angle to straight edge. (

Question 34

JVP elevated

Answer 34

Severe right heart failure, tricuspid insufficiency, constrictive pericarditis, cardiac tamponade.

Question 35

Central Venous Pressure

Answer 35

CVP: 5cm + JVP (normal: 7cm, upper limit 9)

Question 36

Assessment of pulses

Answer 36

``` Compare bilaterally (except carotid), press against body prominence, use index and long finger pads Rate, rhythm, pulse contour, amplitude, symmetry, and obstructions. ```

Question 37

Arterial Pain

Answer 37

Comes on quickly during exercise Relieved quickly by rest Degree of pain correlates to intensity and duration of exercise

Question 38

Venous and Musculoskeletal Pain

Answer 38

Come on during or after exercise Relieved by rest by afters hours or days Pain tends to be constant Greater variability in pain than arterial