Peripheral vascular system examination Flashcards
Peripheral vascular examination: What are the signs of acute ischaemia?
Limb is: Pale Pulseless Painful Paralysed Paraesthetic Perishingly cold. Surgical emergency.
Peripheral vascular examination: arterial, inspection
Look for scars of previous surgery and signs of peripheral arterial disease: loss of hair, pallor, shiny skin, cyanosis, dry skin, scaling, deformed toenails, ulcers, gangrene.
Be sure to inspect the pressure points, i.e. between the toes and under the heel.
Peripheral vascular examination: arterial, palpation
Skin temperature will be cool in peripheral arterial disease. Test bilaterally in thighs, legs and feet.
Is there a level above which it is warm?
Delayed capillary refill (>2s) also indicates arterial disease. Squeeze big toe until it blanches, release, and measure time for colour to return.
Are peripheral pulses palpable or not? radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis. rate? rhythm? volume and character for brachial and carotid?
If you cannot count it, you are not feeling it.
Note down on a quick stickman diagram where they become palpable.
Check for AF or other arrhythmias, as these can be the cause of embolic disease.
Palpate for an enlarged abdominal aorta and attempt to assess size (don’t press too firmly).
An expansile pulsatile mass in the presence of abdominal symptoms is a ruptured aneurysm until proven otherwise.
Peripheral vascular examination: arterial, auscultation
The presence of bruits suggests arterial disease.
Listen over the major arteries- carotids, abdominal aorta, renal arteries, iliac, femoral.
Peripheral vascular examination: arterial, special tests
Buerger’s angle is that above the horizontal plane which leads to development of pallor (<20 degrees indicates severe ischaemia).
Buerger’s sign is the sequential change in colour from white to pink, upon return to the dependent position- if the limbs become flushed red (reactive hyperaemia) this is indicative of more severe disease.
Lift both legs to 45 degrees above the horizontal, supporting at the heels.
Allow a minute for legs to become pale.
If they do, ask patient to sit up and swing around to lower legs to ground- observe colour change.
Peripheral vascular examination: arterial, complete your examination
Measure ABPI.
US Doppler assessment.
Neurological examination of lower limbs.
Peripheral vascular examination: venous, inspection
Start with patient standing.
Look for any varicosities and decide whether they are the long saphenous vein (medial), short saphenous vein (posterior lateral, below the knee) or from the calf perforators (usually few varicosities but commonly show skin changes).
Ulcers around the medial malleolus are more suggestive of venous disease, whereas those at the pressure points suggest arterial pathology.
Brown haeomsiderin deposits result from venous hypertension.
There may also be atrophy and loss of skin elasticity (lipodermatosclerosis) in venous disease.
Peripheral vascular examination: venous, palpation
Warm varicose veins may indicate infection.
Are they tender?
Firm, tender varicosities suggest thrombosis.
Palpate the saphenofemoral junction for a saphena varix which displays a cough impulse.
Similarly, incompetence at the saphenopopliteal junction may be felt as a cough impulse.
If ulceration is present, it is prudent to palpate the arterial pulses to rule out arterial disease.
Peripheral vascular examination: venous, tap test
A transmitted percussion impulse from the lower limit of the varicose vein to the saphenofemoral junction demonstrates incompetence of superficial valves.
Peripheral vascular examination: venous, auscultation
Bruits over the varicosities means there is an arteriovenous malformation.
Peripheral vascular examination: venous, doppler
Test for the level of reflux.
On squeezing the leg distal to placement of the probe, you should only hear one ‘whoosh’ if the valves are competent at the level of probe placement.
Peripheral vascular examination: venous, complete your examination
Examine the abdomen, pelvis in females, and external genitalia in males for masses, PR exam.
