Vascular Surgery Examination Flashcards
What are the pressure points on the foot?
Heel and ball of the foot; in between the toes
What should you look for on inspection?
Scars from previous surgery Signs of peripheral arterial disease Loss of hair Pallor Shiny skin Cyanosis Dry skin Scaling Deformed toe nails Ulcers Gangrene Inspect pressure points
What is indicated by cool peripheries
Ischaemia
What is suggested by the presence of bruits?
Arterial disease
What is indicated by an expansile pulsitile abdominal mass?
AAA until proven otherwise
How is lower limb ischaemia classified?
I: Asymptomatic
II: Intermittent claudication
III: Night/rest pain
IV: Tissue loss (ulceration/gangrene)
What is indicated by a cyanosed, warm foot which is not infected?
Venous disease
If the foot is oedematous, what does this suggest about the origin of claudication pain?
It is venous
If pulses are reduced or absent what does this suggest about the origin of claudication pain?
It is arterial
What are the common causes of acute limb iscaemia?
- Embolic- usually cardiac in origin
- Thrombotic- with occlusion of narrowed athersclerotic arterial segment
- Compartment syndrome- there is increased pressure in a fascial compartment often followin trauma which compromises the perfusion and viability of the compartmental structures
What is the common cardiac association with embolic limb ischaemia?
Atrial fibrillation
How does a TIA differ from a stroke?
TIA: symptoms last 24 hours
What is the difference between embolic and thrombotic ischaemia in terms of onset and severity
Embolic: sudden acute onset (seconds or minutes) with no history of claudication. Ischaemia is profound as there are no pre-existing collaterals
Thrombotic: Insidious onset over hours or days with history of claudication. The ischaemia is less severe due to pre-existing collaterals
What is the most common misdiagnosis for an AAA?
Renal colic- a man >60 with renal colic should be considered to have a ruptured AAA unless proven otherwise
What is Raynaud’s syndrome?
Digital ischaemia induced by cold
What are the three phases of Raynaud’s disease/syndrome?
- Pallor: due to digital artery spasm and/or obstruction
- Cyanosis: due to deoxygenation of static venous blood
- Redness: due to reactive hyperaemia
Why is it important to esquire into sexual activity in patients presenting with some types claudication?
Men with guteal claudication due to internal iliac disease invariably suffer from erectile dysfunction. Patients are often extremely concerned by this symptom but are too embarrassed to mention it
Describe Buerger’s test
With the patient lying supine, stand at the foot of the bed. Raise the patient’s feet and support the legs at 45° to the horizontal for 2-3 minutes.
Then ask the patient to sit up and hang his or her legs over the edge of the bed. Watch the patient’s feet for another 2-3 minutes.
Pallor on elevation (with emptying or ‘guttering’ of the superficial veins), followed by reactive hyperaemia (rubor) on dependency, is a positive test and implies significant PAD.
Which pulses should be measured in the arms and neck?
Carotid, brachial, radial
Why should blood pressure be measured in both arms? What is a normal difference?
It is measured in both arms to look for subclavian artery disease (subclavian steal syndrome)
Discrepancy of 10mmHG or less is normal
If the discrepancy is greater than this the higher value is the true pressure
Which pulses are you palpating for in the legs?
Femoral
Popliteal
Posterior tibial
Dorsalis perdis
How should you feel for the popliteal pulse?
Flex the patients knee to 30 degress and, with your thumb in front of the knee and two fingers behind, press firmly in the midline over the popliteal artery.
How should you feel for the posterior tibial pulse?
Feel 2cm below and 2cm behind the medial malleolus using the pads of your index, middle and ring fingers
How should you feel for the dorsalis pedis pulse?
Using the pads of your index, middle and ring fingers, feel in the middle of the dorsum of the foot, just lateral to the tendon of extensor hallucis longus
Where should you listen for bruits?
Neck region (carotids) Abdomen (renal and aortic) Groin (femoral)
How is an ABPI measurement carried out?
Use a hand-held Doppler and a sphygmomanometer. The probe is held in turn over the three pedal arteries (posterior tibial, dorsalis pedis, perforating peroneal) while inflating a blood pressure cuff round the ankle. The pressure at which the Doppler signal disappears is the systolic pressure in that artery as it passes under the cuff. The ratio of the highest pedal artery pressure to the highest brachial artery pressure is the ABPI.
Normally the ABPI is >1.0 when the patient is supine. Typical values in claudication and critical limb ischaemia are <0.4 respectively. Absolute values may be less informative than the trend over time.
What four things do you palpate for in an arterial exam?
Temperature
CRT
Peripheral pulses
Abdominal aorta
What do you inspect for during a venous system physical examination?
Colour changes, selling and superfical venous dilatation and tortuosity
What do you palpate for during a venous system physical examination?
Differences in temperature
Pitting oedema
(see how far up the leg the oedema extends)
If a patient has pitting oedema in their leg, what should you look for next?
Raised JVP- indicates cardiac disease or pulmonary hypertension is causing oedema
What is indicated by ulcers around the medial malleolus?
Venous disease
What is suggested by warm varicose veins?
Infection
What is indicated by tender, firm varicose veins?
Thrombosis
What are the two main venous junctions in the leg?
Saphenofemoral junction (SFJ) Saphenopopliteal junction (SPJ)
What causes pigmentation in venous insufficiency?
Deposition of haemosiderin in the skin from breakdown of extravasated blood
What is demonstrated by the cough impulse?
Palpate over the SFJ and then SPJ whil asking the patient to cough. If there is incompetence at either of these junctions it will be felt as an impulse beneath your finger
What is the Trendelenburg test?
Ask the patient to sit on the edge of the examination couch and elevate the limb as far as is comfortable for the patient.
Then empty the superficial veins by ‘milking’ the leg.
With the patient’s leg still elevated, press with your thumb over the saphenofemoral junction. A high thigh tourniquet can be used instead of digital pressure
Ask the patient to stand while you maintain pressure over the saphenofemoral junction
If saphenofemoral junction is present, the patients varicose veins will not fill until the pressure from the tourniquet is removed.
This demonstrates the level of reflux
What is the likely cause of a pulsitile mass below the umbilicus?
iliac artery aneurysm
What should be done if a popliteal artery is unexpectedly easy to palpate?
Abdominal ultrasound to exclude AAA
Why is bandaging for leg ulcers initially contraindicated?
1 in 5 patients with a venous ulcer will have significant arterial disease. Bandaging for leg ulcer is therefore contraindicated unless there is evidence of adequate arterial circulation following ABPI measurement
