Clinical Examination of VASCULAR PATIENTS. Stephanie Hirst & Alexander Sunde

Transcription

1 Clinical Examination of VASCULAR PATIENTS Stephanie Hirst & Alexander Sunde

2 Goals of Medical History To record the patient s symptoms at time of presentation. To organize the events which have lead to presentation. To summarize the evidence which supports the diagnostic hypothesis. To provide basis and direction for care

3 Goals of Physical Exam To record the state of patient s health at the time of the examination. To provide a longitudinal record of the patient s health. Allow assessment of progression of disease. Allow prognostication of natural history. Allow recommendations for care.

4 Vascular Examination The exam includes several parts: Position/Lighting/Draping Inspection Palpation Auscultation Special maneuvers

5 Position/Lighting/Draping Position patient should be lying in the supine position, and patient's hands should remain at his/her sides. with the head resting on a pillow. Lighting adjusted so that it is ideal. Draping expose the body surfaces, but use the draping so that the patient feels less exposed. Eg. Between legs while checking for femoral pulse.

6 Blood Pressure Always check blood pressure on both arms Normally, there is a difference in pressure of 5 mmhg up to 10 mmhg Pressure difference of more than mmhg occurs in subclavian steal syndrome, aortic dissection. YES!

7 Inspection On inspection the physician looks for signs of: trauma previous surgery (scars) muscle wasting/muscle asymmetry edema (swelling) erythema (redness) ulcers arterial ulcers tend to be on the borders / sides of the foot, neuropathic ulcers on the plantar surface of the foot, venous ulcers tend on be on the medial aspect of the leg superior to the medial malleolus. hair hair is absent in peripheral vascular disease (PVD) shiny skin seen in PVD Haemosiderin deposits Lipodermatosclerosis

8 Inspection When you examine the extremities, always note: Their size and symmetry; And ALWAYS compare left and right side

9 Palpation Temperature cool suggest poor circulation,both sides should be compared Pitting edema should be tested for in dependent locations dorsum of foot, if present then on the shins. If the patient has been in bed for a longer period of time one should check the sacrum. Capillary refill the time taken for color to return to a nail after pressure is applied to cause blanching Normal: 2 sec or less Bordeline: 3 sec Ischemia: more than 5 sec

10 5 P's signs of acute ischemia Pallor Pain Pulsless Parasthesia Paralyse Poikylothermia

11 Pitting Edema Example of pitting edema in a patient with liver failure

12 Arterial Pulses Always compare both sides Dorsalis pedis artery pulse on dorsal surface of the foot, running lateral to the tendon of the first toe Posterior tibial artery pulse posterior and inferior to the medial malleolus Popliteal artery pulse behind the knee, typically done with both hands Femoral artery pulse in the femoral triangle / halfway between the ASIS and pubic tubercle

13 Dorsalis Pedis Posterior Tibialis

14 Femoral artery Popliteal Pulse

15 Arterial Pulses Always compare both sides Radial artery pulse on the flexor surface of the wrist laterally. Brachial artery pulse flex the elbow slightly, and palpate artery just medial to the biceps tendon at the antecubital crease. It can also be felt higher up in the groove between biceps and triceps muscles. Carotid artery plulse Subclavian artery pulse

16 Carotid Artery Exam

17 Subclavian Artery Exam

18 Ausculatation for Bruits Palpate carotid upstroke, and auscultate for bruits. Auscultate for aortic, renal, and femoral bruits; palpate aorta and determine maxmimal diameter.

19 Aortic Aneurysm Examination - palplate aorta and detemine maximal diameter

20 Special maneuvers Buerger's Test Assesment of arterial sufficiency With the patient supine, note the colour of the feet soles. They should be pink. Then elevate both legs to 45 degrees for more than 1 minute. Observe the soles. If there is marked pallor whiteness, ischemia should be suspected. Next check for rubor of dependency. Sit the patient upright and observe the feet. In normal patients, the feet quickly turn pink. If, more slowly, they turn red like a cooked lobster, suspect ischemia.

21 Special maneuvers Venous Refill Venous refill with dependency (should be less than 30 seconds) the vein should bulge outward within 30 seconds of limb elevation for one minute.

22 Special maneuvers Brodie-Trendelenburg Test assessment of valvular competence if varicose veins are present: One leg at a time. With the patient supine, empty the superficial veins by 'milking' the leg in the distal to proximal direction. Now press with your thumb over the saphenofemoral junction (2.5 cm below and 2.5 cm lateral to the pubic tubercle) and ask the patient to stand while you maintain pressure. If the leg veins now refill rapidly, the incompentence is located below the saphenofemoral junction, and vice versa. This test can be repeated using pressure at any point along the leg until the incompetence has been mapped out.

23 Brodie-Trendelenburg Test

24 Perthes Test The Perthes test is a clinical test for assessing the patency of the deep femoral vein prior to varicose vein surgery. The limb is elevated and an elastic bandage is applied firmly from the toes to the upper 1/3 of the thigh to obliterate the superficial veins only. Modified: The test is done by applying a tourniquet at the level of the sapheno-femoral junction to occlude the superficial pathway, and then the patient is asked to move in situ. If the deep veins are occluded, the dilated veins increase in prominence. This is a more objective test as it does not depend on patient's pain threshold.

25 Pratts Test The Pratt Test is a simple test to check for deep vein thrombosis in the leg. It involves having the patient lie supine with the leg bent at the knee, grasping the calf with both hands and pressing on the popliteal vein in the proximal calf. If the patient feels pain, it is a sign that a deep vein thrombosis exists.

26 Special maneuvers Allen Test The patient should rest with arms in lap, palms up. Ask the patient to make a tight fist with one hand; Then compress both radial and ulnar arteries firmly between your thumbs and fingers. Next, ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale. Release the pressure over ulnar artery. If ulnar artery is patent, the palm flushes within about 3 5 seconds. You can du the same with radial artery while still compressing ulnar artery. It is also a good test to use before taking blood samples from the radial artery.

27 Special maneuvers Allen Test

28 Bedside Examination Ankle-brachial Index (ABI) assesses peripheral vascular disease and find the cutpoint. It may however be unreliable in patients with calcified arteries in the calf (often diabetic patients) or those with extensive oedema. In which case Toebrachial index (TBI) should be performed to aid in the diagnosis. Physiology: higher pressure in ankle ABI: 1,2mmHg Pathology: ABI: < 0,9mmHG

29 ABI

30 Bedside Examination Doppler Examination Continuous Wave Doppler Assessment (Hand held Doppler):- 8MHz.

31 Vascular Physical Exam Examination Instrument Student Worksheet -- Specific Observations 1. Pulses -- should note quality (-, +, ++) right left Superficial Temporal Common Carotid Brachial Radial Aorta Common Femoral Popliteal Dorsalis Pedis Posterior Tibialis 2. Aneurysms (yes, no) right left Aorta Common Femoral Popliteal left Common Carotid Aorta Common Femoral 3. Bruit (yes, no) right 4. Ischemic Signs -- signs of arterial disease. (normal, abnormal; yes, no; If yes, location) right left Color Temperature Capillary Refill Ulceration Eschar Location 5. Venous Signs -- signs of venous disease. (yes, no. If yes, location) Brawny Color Varicose Veins Ulceration Edema Location

32 Vascular Physical Exam Assessment Instrument Did the student examine and record the following? YES NO 17 pulses 5 aneurysms 5 bruit 6 sings of arterial disease 5 signs of venous disease explain examination procedure position patient correctly uncover the skin of the part to be examined. inspect auscultate with stethoscope on skin touch skin (no through clothing or dressing) palpate for aortic aneurysm between umbilicus and xyphoid palpate for popliteal pulse or aneurysm with two hands stand at foot of patient while palpating dorsalis pedis and posterior compress ankle to assess edema feel toes to asses temperature press toes to asses refill Totals: tibial

33 Sources BOOK: Bates' Guide to physical examination and history taking, 11 th ed. By Lynn S. Bickley INTERNET: Wikipedia: on SEMINAR

34 THANK YOU!