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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