VASCULAR EXAMINATION

Set-up: on the bed, flat table, legs exposed (cover groin and thigh; drape between legs)

1. Are you in pain?

2. Take Radial pulse and BP

3. Inspection:

Scars – eg saphenous graft
Muscle wasting/asymmetry; Absence of hair? (found in PVD)
Oedema, erythema, shiny skin (found in PVD)
Gait region – looking for signs of Venous disease
- eg. Chronic skin changes
- eg. Haemosiderin deposits (due to leakage of serum and RBC into surrounding tissues in Venous insufficiency)
- eg. Lipodermatosclerosis (in venous insufficiency: leakage and inflammation around ankles → hardening and woody appearance = “woody fibrosis” = lipodermatosclerosis)
Feet
- Ulceration and tissue loss

with arterial disease, looking at points of pressure at the distal limb
- malleoli, heel, great toe, 5th metatarsal, tips of toes, between toes

IF YOU FIND AN ULCER:

Describe it
- Size, shape, cleanliness of borders, “punched out”? Etc.
Describe location:
- the more distal, the more likely it → Arterial insufficiency
- if in “gait region” i.e. shins → Venous insufficiency
- if on pressure areas (eg. Heel, malleoli (as above)) → Pressure ulcer
- if on plantar surface of foot → Diabetic foot ulcer (esp. in a diabetic patient!)
  - this may be non-painful (if loss of neuro sensation), but not always
- Also could be Trauma Ulcer
Look at surrounding skin
- cleaner surrounds → Arterial
- Uglier surrounds → Venous

4. Buerger's Test

Elevate legs (BOTH) to 45 degrees.
- Observe for a 20-30 second period → looking for pallor in either/both feet
  - this indicates arterial insufficiency because the vessels cannot pump against gravity (normal circulation should get no pallor even at 90 degrees).
- Once you suspect arterial insufficiency, get patient to dangle feet over edge of bed (“dependent” position). Should observe slow change to a red appearance (normal would be rapid return to pink) – this is “reactive hyperaemia”

5. Palpation:

Abdominal aorta
Femorals
- find ASIS. find pubic symphysis. Midpoint of these. Then move 2cm down, and feel in a vertical manner (fingers in a line up/down the body)
- middle of the groin – tuck under inguinal ligament, in the top of the thigh
Popliteal
- sit on the bed, so you are comfortable and supported.
- bend knee at 90 degrees
- wrap hands around – thumbs on tibial tuberosity
- press firmly – this is tough – take time!
Posterior Tibial – Posterior tibial a.
- Behind the Medial malleolus
- If don't feel in typical anatomical place, can be a bit more distal or proximal
Dorsalis Pedis – Anterior tibial a.
- PROXIMAL foot – between 1st and 2nd metatarsals
- Feel with a ROW of fingers – thumb on underside of foot

6. Auscultation:

Upper abdomen
- indicates stenosis of either Abdo aorta, mesenteric aa.Or renal aa.
Groin
- indicates stenosis of Femoral aa.

7. Other extra Tests

a. Ankle-brachial pressure index (ABPI)

Place BP cuff on ankle – use Doppler U/S to assess blood flow. Continue inflating until get cessation of pulsation. Deflate until get re-commencement. This is the Systolic BP @ the Posterior Tibial/Dorsalis Pedis aa.
Repeat above, except use at upper limb to assess Brachial artery.
NORMAL = 0.9-1.2
<0.5 = Crap = Severe arterial disease.
ISSUE: unreliable on patients with calcified atheromatous arteries, found esp. in Diabetes
- this will mean that ankle P will appear higher, therefore ABPI might be normal, when it really isn't!

b. Brodie-Trendelenberg Test?

	Created by DSCOgnenis almost 11 years ago

Note on VASCULAR EXAMINATION, created by DSCOgnenis on 07/09/2013.

VASCULAR EXAMINATION