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PHYSICAL EXAMINATION of the VASCULAR SYSTEM

PHYSICAL EXAMINATION of the VASCULAR SYSTEM. Hugh Gelabert, M.D. Vascular Surgery Division UCLA School of Medicine. Today’s Objective. To review the examination of the Vascular System To review exam techniques To discuss common findings

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PHYSICAL EXAMINATION of the VASCULAR SYSTEM

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  1. PHYSICAL EXAMINATIONof theVASCULAR SYSTEM Hugh Gelabert, M.D. Vascular Surgery Division UCLA School of Medicine

  2. Today’s Objective • To review the examination of the Vascular System • To review exam techniques • To discuss common findings • To review the correlation between patient symptoms and exam findings

  3. Goal 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 diagnostic hypothesis. • To provide basis and direction for care.

  4. 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.

  5. Vascular Physical Exam Arterial Anatomy Goals • establish presence and quality of pulses • establish presence or absence of findings: aneurysms, arterial bruit, signs of ischemia, signs of venous disease

  6. ARTERIAL ANATOMY

  7. ARTERIAL ANATOMY

  8. ARTERIAL ANATOMY

  9. Vascular Physical Exam Dorsalis Pedis Posterior Tibialis

  10. Vascular Physical Exam Femoral Artery Popliteal Pulse

  11. Vascular Physical Exam Aortic Aneurysm Exam

  12. Vascular Physical Exam Subclavian Artery Exam

  13. Vascular Physical Exam Carotid Artery Exam

  14. Vascular Physical Exam Bruit • Sound made by vibrating arterial wall • Caused by turbulent blood flow making arterial wall vibrate • Indicates the presence of an arterial lesion

  15. Vascular Physical Exam Vascular Findings • Generally related to • Blockage of blood vessel • Dilatation of blood vessel • Subsequent events • Ischemic tissue • Gangrenous tissue

  16. Vascular Physical Exam Ischemia • Decreased blood supply results in metabolic compromise. • Grades of severity reflect acuity of condition as well as the magnitude of the reduction in circulation. • ACUTE vs CHRONIC

  17. Vascular Physical Exam Acute Ischemia • 5 ‘P’s • Pulseless • Pain • Pallor • Paresthesia • Paralysis • Poikilothermia (Cold)

  18. Acute Ischemia

  19. Vascular Physical Exam Acute Ischemia • An abrupt disruption of the normal blood supply to a vascular bed. • Example: • Gunshot wound • Fracture • Tourniquette • Embollus

  20. Vascular Physical Exam Acute Ischemia • Implies that without prompt restoration of blood supply there will be significant permanent damage to tissues. • Susceptibility to Acute Ischemic Injury • Nerve +++ • Muscle ++ • Tendon and Bone +

  21. Vascular Physical Exam Chronic Ischemia • A process where the gradual onset and magnitude of ischemia has allowed the body time to compensate for the decreased blood supply. • Key Concept: “Collateral Circulation” • Compensation is never as good as original. • The vascular bed survives with less blood.

  22. Vascular Physical Exam Chronic Ischemia • Changes in the Limbs • Skin …………………... Growth slowed • Nails beds …………… Growth slowed • Hair follicles ……. Lost • Sebaceous glands …… Lost • Result: Thin, dry, skin with loss of hair, abnormal nail growth / fungal infections.

  23. Vascular Physical Exam Capillary Refill • The time required for capillary system to refill following compression of the nail bed or finger pad. • Normal should be rapid (1 sec or less) • Decreased • Normal physiologic response (eg. cold) • Abnormal vasomotor tone (eg. Raynaud’s) • Acute Ischemia • Chronic Ischemia

  24. Vascular Physical Exam Capillary Refill • In the chronic ischemic limb: • Pallor on Elevation • Insufficient arterial pressure to perfuse when leg elevated above level of heart. • Limb drains of blood. • Dependent Rubror • Blood pooling in maximally dilated capillary bed • Cyanosis -- when blood is de-oxygenated

  25. Tissue Refill Venous Guttering Buerger’s test

  26. Vascular Physical Exam Capillary Refill • In Acute Ischemia • Cyanosis noted because blood hemoglobin is desaturated of oxygen • Compression of digit results in evacuation of blood from capillaries • Refill of blood is sluggish because of decreased arterial pressure. • In severe cases the blood in capillaries may thrombose and will not blanch on palpation

  27. Cyanosis with acute ischemia

  28. Vascular Physical Exam Ulceration • A discontinuity in the integrity of the skin which persists despite sufficient time for healing. • Must be able to distinguish three types: Arterial, Venous, Neuropathic.

  29. Ulcers Differential Presentation of Ulcers ArterialVenousNeuro Location distal maleolar plantar Symptoms painful + / - no pain Outline sharp irregular punched Assoc findings Art sx CVI sx other Dx no pulse OK pulse OK pulse

  30. What kind of ulcer ?

  31. Neuropathic Plantar location Punched Out margins Insensate

  32. What kind of ulcer ?

  33. Arterial Ulcer Distal location Sharp margins Painful

  34. What kind of ulcer ?

  35. Venous Ulcer Maleolar location Irregular margins Insensate or Painful

  36. Ulcers VENOUS DIABETIC ARTERIAL

  37. Gangrene: Necrosis or death of tissue. Decubitus Eschar

  38. Vascular Physical Exam Gangrene • Death of tissue • Related to absent blood supply • Infections • Tissue Toxins • Radiation, Trauma • WET Gangrene vs DRY Gangrene • Bacterial superinfection • Mumefaction or mumyfication

  39. Wet Gangrene

  40. Dry Gangrene

  41. Gangrene A dynamic process develops where tissues becomes ischemic with acute necrosis, autolysis and liquefaction. In the absence of superinfection the tissue gradually dessicates and becomes mummyfied. Later, eschar separation and auto-amputation take place.

  42. Blue Toe Syndrome

  43. Digital Embolizationa

  44. Vascular Physical Exam Process of Auto Amputation • Dry Gangrene of Digit • Tissue dessicates • Demaracation • Eschar separation • Epidermal ingrowth • Wound margin contraction • Osteolysis

  45. Auto-amputation

  46. Vascular Physical Exam Methods:Prepare your patient for exam: • be sure room temperature is correct • be sure limb position is as needed • be sure privacy is respected • place patient in correct position: supine on exam table is generally best • uncover area to be examined

  47. Vascular Physical Exam Methods: Discuss what you are about to do • inform patient of intention of examination • explain how exam will be conducted

  48. Vascular Physical Exam Methods: Prepare Yourself for the Exam • approach exam systematically • compare bilaterally • review patient complaints as exam progresses

  49. Vascular Physical Exam Methods: Follow Exam Sequence • observe • auscultate • lightly touch • palpate • compress

  50. PULSES -- should note 17 pulses. -- quality (-, +, ++) Temporal x 2 Carotid x 2 Brachial x 2 Radial x 2 Aorta x 1 Femoral x 2 Popliteal x 2 Dorsalis Pedis x 2 Posterior Tibialis x 2 Vascular Physical Exam Specific Observations

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