BATES VISUAL GUIDE TO PHYSICAL EXAMINATION. Vol. 11: Peripheral Vascular System
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1 BATES VISUAL GUIDE TO PHYSICAL EXAMINATION Vol. 11: Peripheral Vascular System Hello, Mrs. Roth, welcome to our clinic. Thank you. Your learning objectives for mastering the examination of the Peripheral Vascular System are: to assess the arterial pulses brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial; to screen for peripheral arterial disease (PAD) in the abdominal aorta and renal arteries and in the extremities; and to assess the lower extremity venous system and the lymphatic system, including the axillary and epitrochlear lymph nodes and the inguinal lymph nodes, and to identify edema. Careful assessment of the peripheral vascular system is essential for detection of peripheral artery disease, which is found in roughly 12% of the population, but silent in about half of those affected. Anatomy Review Let s briefly review the anatomy of the peripheral vascular system. The peripheral vascular system consists of the circulatory vessels to the arms and legs, including arteries, veins, the capillary bed that connects them, and the lymphatic system with its lymph nodes. Arteries carry oxygenated blood away from the heart and contain three concentric layers of tissue: the intima, the media, and the adventitia. Surrounding the lumen of the arteries is the intima, a single continuous lining of endothelial cells with remarkable metabolic properties. The media is composed of smooth muscle cells that dilate and constrict to accommodate blood pressure and flow. The outer layer of the artery is the adventitia connective tissue containing nerve fibers and the vasa vasorum. When arteries lie close to the body surface, you can feel their pulsation. In the arms, arterial pulses are palpable in three locations: the brachial artery at and above the bend of the elbow medial to the biceps tendon and the muscle; the radial artery on the lateral ventral surface of the wrist; and the ulnar artery on the medial ventral surface of the wrist, though overlying tissues frequently obscure this pulse. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 1
2 The arterial arches interconnect the radial and ulnar arteries and help protect hand and finger circulation from arterial occlusion. In the legs, arterial pulses can usually be felt in four places: the femoral artery just below the inguinal ligament, midway between the superior iliac spine and the symphysis pubis; the popliteal artery, an extension of the femoral artery that passes medially behind the distal femur and palpable just behind the knee; the dorsalis pedis artery on the dorsum of the foot, just medial to the extensor tendon of the big toe; and the posterior tibial artery behind the medial malleolus of the ankle. An interconnecting arterial arch protects the circulation of the foot. Veins are thin walled and highly distensible, with a capacity for up to two thirds of circulating blood flow. Because the veins of the leg are especially susceptible to venous stasis, they warrant special attention. Deep leg veins, which carry approximately 90% of venous return from the lower extremities, include the femoral vein, which lies just medial to the femoral artery below the inguinal ligament. Superficial leg veins are subcutaneous with relatively poor tissue support and include the great saphenous vein, which runs medially from the dorsum of the foot to the groin, and the small saphenous vein, which runs from the side of the foot to the back of the knee. Bridging or perforating veins connect the superficial system with the deep system. The lymphatic system is an extensive vascular network that drains lymph fluid from body tissues and returns it to the venous circulation. Lymph nodes are round, oval, or bean shaped structures that vary in size according to their location. Only superficial lymph nodes are accessible to physical examination. In the arms, these include the epitrochlear nodes, lateral axillary nodes, and central axillary nodes. The infraclavicular nodes may also be palpable. In the legs, usually only the superficial inguinal nodes are palpable. The horizontal group lies in a chain high in the anterior thigh below the inguinal ligament. The vertical group clusters over the upper part of the great saphenous vein. Blood circulates from arteries to veins through the capillary bed. Blood pressure or hydrostatic pressure within the capillary bed, especially near the arteriolar end, forces fluid out into the tissue spaces. As blood continues toward the venous end, the colloid oncotic pressure of plasma proteins, pulls fluid back into the vascular tree. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 2
3 Health History Common or concerning symptoms relating to the peripheral vascular system include: abdominal, flank or back pain; pain in the arms or legs; intermittent claudication, which is any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes; cold, numbness, or pallor in the legs; hair loss in the extremities; swelling in the calves, legs, or feet; color change in the fingertips or toes in cold weather; and swelling with redness or tenderness. Ask about abdominal, flank, or back pain, especially in older smokers. Is there unusual constipation or distention, or any urinary retention, difficulty voiding, or renal colic these symptom can suggest an expanding hematoma from an abdominal aortic aneurysm. You should be familiar with the warning signs of peripheral arterial disease claudication. Note any non healing wounds of the legs or feet and abdominal pain after meals, or food fear, suggesting mesenteric ischemia. Screening by the ankle brachial index and abdominal, renal, or arterial ultrasound may be indicated. Examining the Arms With the patient s health history in mind, and after good hand hygiene, you are ready for the physical examination. Mrs. Roth, first I m going to just look at your hands and arms from the point of view of how the circulation is looking. To examine the peripheral vascular system, begin by inspecting both arms from the fingertips to the shoulders. Note their size, symmetry, and any swelling. Also note the venous pattern, the color of the skin and nail beds, and the texture of the skin. Assess the skin temperature of the hands and lower arms with the sensitive backs of your fingers, comparing both sides. If you detect unusual coolness or temperature differences, check further up the arms. Next, palpate the radial pulses using the pads of your fingers on the flexor surface of the wrist laterally. Compare the pulses in both arms, and grade the amplitude. A grade of 0 indicates an arterial pulse that is absent and not palpable. A grade of 1 plus indicates a pulse that is diminished weaker than expected. A grade of 2 plus indicates a brisk or normal pulse. Grade 3 plus indicates bounding and possible aortic insufficiency. If you suspect arterial insufficiency palpate the brachial pulse by flexing the patient s elbow slightly, and palpate the artery just medial to the biceps tendon at the antecubital crease. The brachial artery can also be felt higher in the arm in the groove between the biceps and triceps muscles. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 3
4 To evaluate the arterial supply to the hand, perform the Allen test. Tell the patient to clench her fist tightly. Then, firmly compress both arteries with your thumbs and fingers. Have the patient open and relax her hand. Note the color of her palms and fingers, which should be pale. Then, release the pressure over just the ulnar artery. If the artery is patent, the palm should flush within about 3 to 5 seconds. To assess the patentcy of the radial artery when indicated, repeat these steps, but this time release the pressure over the radial artery. Next, try to feel for one or more of the epitrochlear nodes. With the patient s elbow flexed at approximately 90 degrees and your hand supporting the forearm, feel in the groove between the biceps and triceps muscles about 3 centimeters above the medial epicondyle. If the epitrochlear node is palpable, note its size, consistency, and tenderness. These nodes are difficult or impossible to identify in most healthy people. Examining the Abdomen With the patient lying down and properly draped, examine the abdominal aorta, and listen for aortic, renal, and femoral bruits. Palpate adjacent to the aorta on both sides, then estimate its width in the epigastric area by measuring the span between two fingers, especially in older adults. Note the presence of a pulsatile mass, suspicious for an abdominal aortic aneurysm. Examining the Legs To examine the legs, the patient should be draped so that the lower abdomen and genitalia are covered but the legs are fully exposed. Socks or stockings should be removed. Inspect both legs from the groin and buttocks to the feet, noting symmetry in size, shape, and color. Also, note areas of swelling, pigmentation, rashes, scars, ulcers, and abnormal venous patterns. On the lower legs, feet, and toes, observe the color and texture of the skin and nail beds and the distribution of hair. Assess the skin temperature of the feet and lower legs with the backs of your fingers. If you notice unusual coolness or temperature differences, check further up the legs. Arterial insufficiency, or peripheral arterial disease, may be present. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 4
5 Next, palpate the superficial inguinal nodes, including the horizontal group and the vertical group. Note the size, consistency, discreetness, and tenderness of any palpable nodes. Small, mobile, non tender inguinal nodes up to 1 or 2 centimeters in diameter are often palpable in normal adults. Examine the opposite inguinal area in the same way. Next, palpate the femoral pulse by placing your fingers midway between the anterior superior iliac spine and the symphysis pubis. Press deeply below the inguinal ligament. The use of two hands, one on top of the other, may be helpful, especially in obese patients. To examine the popliteal pulse, slightly flex the patient s knee. Press the fingertips of both hands deeply into the popliteal fossa slightly lateral to the mid line. The popliteal pulse is frequently more difficult to find than other pulses because it is deeper and more diffuse. Compare this pulse with the popliteal pulse on the other side. If the popliteal pulse is difficult to find, try this approach. With the patient prone, flex the knee to 90 degrees. Let the lower leg relax against your shoulder or upper arm and press your thumbs deeply into the popliteal fossa. Next, assess the dorsalis pedis pulse by palpating the dorsum of the foot (not the ankle) just lateral to the extensor tendon of the big toe. If you cannot feel the pulse, move laterally. The dorsalis pedis pulse may be congenitally absent or may branch higher in the ankle. Check the posterior tibial pulse by curving your fingers behind and slightly below the medial malleolus of the ankle. This pulse may be hard to find in a thickened or edematous ankle. Now check for edema. Comparing one foot and ankle with the other, note their relative size and the prominence of veins, tendons, and bones. To detect pitting edema, press firmly with your thumb for at least 5 seconds over the dorsum of the feet...behind the medial malleoli...and over the shins. Note any indentation caused by your thumb pressure. Normally there is none. The severity of edema is graded on a 4 point scale from slight to very marked. This example illustrates a 3 plus pitting edema. If edema is present, note the extent of the swelling and how far up the leg it goes. Note if the swelling is unilateral or bilateral. Are the veins unusually prominent? Note the color of the skin for redness or brownish areas near the ankles. Also note any ulcers arising from venous stasis or arterial insufficiency. Assessing for Chronic Arterial Insufficiency Mrs. Roth, next I m going to elevate your leg as to draw all the venous blood from them to see how your vascular pattern looks. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 5
6 If the patient s diminished pulses or pain on walking suggest arterial insufficiency, look for postural color changes using the following technique. Elevate and support both legs to a position about 60 degrees above the examination table. Wait until the feet are drained of venous blood, usually within a minute. Mild pallor of the elevated feet is normal, but watch for unusual pallor. Alright, Mrs. Roth, now I want you to sit up. Then, ask the patient to sit up with legs dangling. Comparing both feet, note how long it takes for the skin to return to its usual color normally about 10 seconds and for the veins of the feet and ankles to fill usually about 15 seconds. In lighter skinned patients, pinking of the skin is easily seen. Rubor, or dusky redness, which may appear gradually in dependent feet, suggests poor arterial circulation. Assessing for Venous Insufficiency Mrs. Roth, now I want you to stand up. To complete the examination, ask the patient to stand in order to allow any varicosities to fill with blood and become more visible. Then inspect the saphenous system for varicosities, noting any signs of thrombophlebitis. If varicose veins are visible, mapping can show which veins are insufficient and their origin. Using two hands and compressing the vein sharply with your lower hand, a palpable pressure wave indicates that the two parts of the vein are connected. You can also assess the competency of the valves in the veins and the saphenous system by elevating one leg of the supine patient to about 90 degrees to empty it of venous blood. Then, occlude the great saphenous vein in the upper thigh and ask the patient to stand. Watch the venous filling in the leg. Normally the saphenous vein fills from below, taking about 35 seconds to do so. After the patient stands for 20 seconds, release the compression and look for sudden additional venous filling. Normally there is none. Recording Your Findings Remember that a clear, well organized clinical record employing language that is neutral, professional, and succinct is one of the most important adjuncts to patient care. [TYPING] Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 6
7 After practice and further review of this video, make sure you have mastered the important learning objectives for examining the peripheral vascular system. Copyright 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 7
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