Bates 11 Peripheral Vascular System Transcript Final PDF

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BATES’VISUALGUIDETOPHYSICALEXAMINATION Vol.11:PeripheralVascularSystem  Hello,Mrs.Roth,welcometoourclinic. Thankyou. YourlearningobjectivesformasteringtheexaminationofthePeripheralVascularSystemare:toassess thearterialpulses—brachial,radial,femoral,popliteal,dorsalispedis,andposteriortibial;toscreenfor peripheralarterialdisease(PAD)intheabdominalaortaandrenalarteriesandintheextremities;andto assessthelowerextremityvenoussystemandthelymphaticsystem,includingtheaxillaryand epitrochlearlymphnodesandtheinguinallymphnodes,andtoidentifyedema. Carefulassessmentoftheperipheralvascularsystemisessentialfordetectionofperipheralartery disease,whichisfoundinroughly12%ofthepopulation,butsilentinabouthalfofthoseaffected.  AnatomyReview Let’sbrieflyreviewtheanatomyoftheperipheralvascularsystem.Theperipheralvascularsystem consistsofthecirculatoryvesselstothearmsandlegs,includingarteries,veins,thecapillarybedthat connectsthem,andthelymphaticsystemwithitslymphnodes. Arteriescarryoxygenatedbloodawayfromtheheartandcontainthreeconcentriclayersoftissue:the intima,themedia,andtheadventitia. Surroundingthelumenofthearteriesistheintima,asinglecontinuousliningofendothelialcellswith remarkablemetabolicproperties. Themediaiscomposedofsmoothmusclecellsthatdilateandconstricttoaccommodatebloodpressure andflow. Theouterlayerofthearteryistheadventitia—connectivetissuecontaining nervefibersandthevasa vasorum. Whenarterieslieclosetothebodysurface,youcanfeeltheirpulsation.Inthearms,arterialpulsesare palpableinthreelocations:thebrachialarteryatandabovethebendoftheelbowmedialtothebiceps tendonandthemuscle;… …theradialarteryonthelateralventralsurfaceofthewrist;and… …theulnararteryonthemedialventralsurfaceofthewrist,thoughoverlyingtissuesfrequently obscurethispulse.

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Thearterialarchesinterconnecttheradialandulnararteriesandhelpprotecthandandfinger circulationfromarterialocclusion. Inthelegs,arterialpulsescanusuallybefeltinfourplaces:thefemoralarteryjustbelowtheinguinal ligament,midwaybetweenthesuperioriliacspineandthesymphysispubis;… thepoplitealartery,anextensionofthefemoralarterythatpassesmediallybehindthedistalfemurand palpablejustbehindtheknee;… thedorsalispedisarteryonthedorsumofthefoot,justmedialtotheextensortendonofthebigtoe; and… …theposteriortibialarterybehindthemedialmalleolusoftheankle. Aninterconnectingarterialarchprotectsthecirculationofthefoot. Veinsarethin‐walledandhighlydistensible,withacapacityforuptotwo‐thirdsofcirculatingblood flow. Becausetheveinsofthelegareespeciallysusceptibletovenousstasis,theywarrantspecialattention. Deeplegveins,whichcarryapproximately90%ofvenousreturnfromthelowerextremities,includethe femoralvein,whichliesjustmedialtothefemoralarterybelowtheinguinalligament. Superficiallegveinsaresubcutaneouswithrelativelypoortissuesupportandincludethegreat saphenousvein,whichrunsmediallyfromthedorsumofthefoottothegroin,andthesmallsaphenous vein,whichrunsfromthesideofthefoottothebackoftheknee. Bridgingorperforatingveinsconnectthesuperficialsystemwiththedeepsystem. Thelymphaticsystemisanextensivevascularnetworkthatdrainslymphfluidfrombodytissuesand returnsittothevenouscirculation. Lymphnodesareround,oval,orbean‐shapedstructuresthatvaryinsizeaccordingtotheirlocation. Onlysuperficiallymphnodesareaccessibletophysicalexamination.Inthearms,theseincludethe epitrochlearnodes,lateralaxillarynodes,andcentralaxillarynodes.Theinfraclavicularnodesmayalso bepalpable. Inthelegs,usuallyonlythesuperficialinguinalnodesarepalpable.Thehorizontalgroupliesinachain highintheanteriorthighbelowtheinguinalligament.Theverticalgroupclustersovertheupperpartof thegreatsaphenousvein. Bloodcirculatesfromarteriestoveinsthroughthecapillarybed.Bloodpressureorhydrostaticpressure withinthecapillarybed,especiallynearthearteriolarend,forcesfluidoutintothetissuespaces. Asbloodcontinuestowardthevenousend,thecolloidoncoticpressureofplasmaproteins,pullsfluid backintothevasculartree. 

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HealthHistory Commonorconcerningsymptomsrelatingtotheperipheralvascularsysteminclude:abdominal,flank orbackpain;paininthearmsorlegs;intermittentclaudication,whichisanypainorcrampinginthelegs duringexertionthatisrelievedbyrestwithin10minutes;cold,numbness,orpallorinthelegs;hairloss intheextremities;swellinginthecalves,legs,orfeet;colorchangeinthefingertipsortoesincold weather;andswellingwithrednessortenderness. Askaboutabdominal,flank,orbackpain,especiallyinoldersmokers.Isthereunusualconstipationor distention,oranyurinaryretention,difficultyvoiding,orrenalcolic—thesesymptomcansuggestan expandinghematomafromanabdominalaorticaneurysm. Youshouldbefamiliarwiththewarningsignsofperipheralarterialdisease—claudication.Noteany non‐healingwoundsofthelegsorfeetandabdominalpainaftermeals,or“foodfear,”suggesting mesentericischemia. Screeningbytheankle‐brachialindexandabdominal,renal,orarterialultrasoundmaybeindicated.  ExaminingtheArms Withthepatient’shealthhistoryinmind,andaftergoodhandhygiene,youarereadyforthephysical examination. Mrs.Roth,firstI’mgoingtojustlookatyourhandsandarmsfromthepointofviewofhowthe circulationislooking. Toexaminetheperipheralvascularsystem,beginbyinspectingbotharmsfromthefingertipstothe shoulders.Notetheirsize,symmetry,andanyswelling.Alsonotethevenouspattern,thecolorofthe skinandnailbeds,andthetextureoftheskin. Assesstheskintemperatureofthehandsandlowerarmswiththesensitivebacksofyourfingers, comparingbothsides. Ifyoudetectunusualcoolnessortemperaturedifferences,checkfurtherupthearms. Next,palpatetheradialpulsesusingthepadsofyourfingersontheflexorsurfaceofthewristlaterally. Comparethepulsesinbotharms,andgradetheamplitude. Agradeof0indicatesanarterialpulsethatisabsentandnotpalpable.Agradeof1‐plusindicatesa pulsethatisdiminished—weakerthanexpected.Agradeof2‐plusindicatesabriskornormalpulse. Grade3‐plusindicatesboundingandpossibleaorticinsufficiency. Ifyoususpectarterialinsufficiencypalpatethebrachialpulsebyflexingthepatient’selbowslightly,and palpatethearteryjustmedialtothebicepstendonattheantecubitalcrease. Thebrachialarterycanalsobefelthigherinthearminthegroovebetweenthebicepsandtriceps muscles.

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Toevaluatethearterialsupplytothehand,performtheAllentest. Tellthepatienttoclenchherfisttightly.Then,firmlycompressbotharterieswithyourthumbsand fingers. Havethepatientopenandrelaxherhand.Notethecolorofherpalmsandfingers,whichshouldbe pale.Then,releasethepressureoverjusttheulnarartery.Ifthearteryispatent,thepalmshouldflush withinabout3to5seconds. Toassessthepatentcyoftheradialarterywhenindicated,repeatthesesteps,butthistimereleasethe pressureovertheradialartery. Next,trytofeelforoneormoreoftheepitrochlearnodes. Withthepatient’selbowflexedatapproximately90degreesandyourhandsupportingtheforearm,feel inthegroovebetweenthebicepsandtricepsmusclesabout3centimetersabovethemedialepicondyle. Iftheepitrochlearnodeispalpable,noteitssize,consistency,andtenderness.Thesenodesaredifficult orimpossibletoidentifyinmosthealthypeople.  ExaminingtheAbdomen Withthepatientlyingdownandproperlydraped,examinetheabdominalaorta,andlistenfor aortic,…renal,…andfemoralbruits. Palpateadjacenttotheaortaonbothsides,thenestimateitswidthintheepigastricareabymeasuring thespanbetweentwofingers,especiallyinolderadults. Notethepresenceofapulsatilemass,suspiciousforanabdominalaorticaneurysm.  ExaminingtheLegs Toexaminethelegs,thepatientshouldbedrapedsothatthelowerabdomenandgenitaliaarecovered butthelegsarefullyexposed. Socksorstockingsshouldberemoved. Inspectbothlegsfromthegroinandbuttockstothefeet,notingsymmetryinsize,shape,andcolor. Also,noteareasofswelling,pigmentation,rashes,scars,ulcers,andabnormalvenouspatterns. Onthelowerlegs,feet,andtoes,observethecolorandtextureoftheskinandnailbedsandthe distributionofhair. Assesstheskintemperatureofthefeetandlowerlegswiththebacksofyourfingers.Ifyounotice unusualcoolnessortemperaturedifferences,checkfurtherupthelegs.Arterialinsufficiency,or peripheralarterialdisease,maybepresent.

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Next,palpatethesuperficialinguinalnodes,includingthehorizontalgroupandtheverticalgroup.Note thesize,consistency,discreetness,andtendernessofanypalpablenodes.Small,mobile,non‐tender inguinalnodesupto1or2centimetersindiameterareoftenpalpableinnormaladults.Examinethe oppositeinguinalareainthesameway. Next,palpatethefemoralpulsebyplacingyourfingersmidwaybetweentheanteriorsuperioriliacspine andthesymphysispubis.Pressdeeplybelowtheinguinalligament. Theuseoftwohands,oneontopoftheother,maybehelpful,especiallyinobesepatients. Toexaminethepoplitealpulse,slightlyflexthepatient’sknee.Pressthefingertipsofbothhandsdeeply intothepoplitealfossaslightlylateraltothemidline. Thepoplitealpulseisfrequentlymoredifficulttofindthanotherpulsesbecauseitisdeeperandmore diffuse.Comparethispulsewiththepoplitealpulseontheotherside. Ifthepoplitealpulseisdifficulttofind,trythisapproach.Withthepatientprone,flexthekneeto90 degrees.Letthelowerlegrelaxagainstyourshoulderorupperarmandpressyourthumbsdeeplyinto thepoplitealfossa. Next,assessthedorsalispedispulsebypalpatingthedorsumofthefoot(nottheankle)justlateralto theextensortendonofthebigtoe.Ifyoucannotfeelthepulse,movelaterally. Thedorsalispedispulsemaybecongenitallyabsentormaybranchhigherintheankle. Checktheposteriortibialpulsebycurvingyourfingersbehindandslightlybelowthemedialmalleolusof theankle.Thispulsemaybehardtofindinathickenedoredematousankle. Nowcheckforedema.Comparingonefootandanklewiththeother,notetheirrelativesizeandthe prominenceofveins,tendons,andbones. Todetectpittingedema,pressfirmlywithyourthumbforatleast5secondsoverthedorsumofthe feet...behindthemedialmalleoli...andovertheshins.Noteanyindentationcausedbyyourthumb pressure.Normallythereisnone. Theseverityofedemaisgradedona4‐pointscalefromslighttoverymarked. Thisexampleillustratesa3‐pluspittingedema. Ifedemaispresent,notetheextentoftheswellingandhowfarupthelegitgoes.Noteiftheswellingis unilateralorbilateral.Aretheveinsunusuallyprominent?Notethecoloroftheskinforrednessor brownishareasneartheankles.Alsonoteanyulcersarisingfromvenousstasisorarterialinsufficiency.  AssessingforChronicArterialInsufficiency Mrs.Roth,nextI’mgoingtoelevateyourlegastodrawallthevenousbloodfromthemtoseehowyour vascularpatternlooks.

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Ifthepatient’sdiminishedpulsesorpainonwalkingsuggestarterialinsufficiency,lookforposturalcolor changesusingthefollowingtechnique.Elevateandsupportbothlegstoapositionabout60degrees abovetheexaminationtable.Waituntilthefeetaredrainedofvenousblood,usuallywithinaminute. Mildpalloroftheelevatedfeetisnormal,butwatchforunusualpallor. Alright,Mrs.Roth,nowIwantyoutositup. Then,askthepatienttositupwithlegsdangling. Comparingbothfeet,notehowlongittakesfortheskintoreturntoitsusualcolor—normallyabout10 seconds—andfortheveinsofthefeetandanklestofill—usuallyabout15seconds.Inlighterskinned patients,pinkingoftheskiniseasilyseen.Rubor,orduskyredness,whichmayappeargraduallyin dependentfeet,suggestspoorarterialcirculation.  AssessingforVenousInsufficiency Mrs.Roth,nowIwantyoutostandup. Tocompletetheexamination,askthepatienttostandinordertoallowanyvaricositiestofillwithblood andbecomemorevisible.Theninspectthesaphenoussystemforvaricosities,notinganysignsof thrombophlebitis. Ifvaricoseveinsarevisible,mappingcanshowwhichveinsareinsufficientandtheirorigin.Usingtwo handsandcompressingtheveinsharplywithyourlowerhand,apalpablepressurewaveindicatesthat thetwopartsoftheveinareconnected. Youcanalsoassessthecompetencyofthevalvesintheveinsandthesaphenoussystembyelevating onelegofthesupinepatienttoabout90degreestoemptyitofvenousblood. Then,occludethegreatsaphenousveinintheupperthigh… …andaskthepatienttostand.Watchthevenousfillingintheleg.Normallythesaphenousveinfillsfrom below,takingabout35secondstodoso. Afterthepatientstandsfor20seconds,releasethecompressionandlookforsuddenadditionalvenous filling.Normallythereisnone.  RecordingYourFindings Rememberthataclear,well‐organizedclinicalrecord—employinglanguagethatisneutral,professional, andsuccinct—isoneofthemostimportantadjunctstopatientcare. [TYPING]Extremitiesarewarmandwithoutedema.Novaricositiesorstasischanges.Calvesaresupple andnontender.

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Afterpracticeandfurtherreviewofthisvideo,makesureyouhavemasteredtheimportantlearning objectivesforexaminingtheperipheralvascularsystem. 

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