VASCULAR EXAMINATION

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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:

General:

temperature, pitting oedema, capillary refill

Pulses:

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?

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