clinical - vascular examination

Peripheral vascular Disease (Ischemia)

History

1-            Risk Factors (smoking, DM, HTN, IHD, Hyperlipidaemia)

2-            Intermittent Claudication

·   Site

a-  Buttocks (Aorto-iliac)

b-  Thigh (Iliac)

c-  Calf (Femoral)

·   Severity: Claudication distance

3-            Rest Pain

·   Site: Forefoot

·   Severity: Hang the leg out of bed / Type of analgesia

4-            Functions

                Lifestyle – Shopping – Walking aids – Limping

Ischemia LL Examination

Introduce yourself

Exposure:  Upto groin & lower abdomen

1-         Inspection من تحت لفوق

·           Color changes in sole (Pallor – Rubor – Cyanosis)

Critical Limb Ischemia

1-Rest Pain > 2 weeks

2-Ulcer or Gangrene

3-ABPI < 0.5

·           Trophic changes:  - Loss of Hair

- Brittle nails  

- Taper toes 

- Interdigital fungal inf. (open between toes)

- Ulcer (heel, head metatars, bet.toes, sole) →3S FED SS

- Heel ulcer (elevate leg)

- Gangrene – amutated toe

·           Venous guttering

·           Scar of previous operation (leg, groin, abdomen)

·           Burger’s test (Lower limb)                   OR              

1- Elevate one LL till pallor (+/-) venous guttering & notice degree (look from side)

     If < 30 degrees → critical ischemia

     If > 30 degrees → chronic ischemia

2- Hang both LL out of the bed till rubor (+/-) venous refilling (due to accumulation metabolites) & notice time

2-         Palpation Ask about pain

·           TT (Temperature from distal to proximal & compare (very imp…) & Tenderness)

·           Capillary refill time: press on big toe away from nail ( Normal: 2-3 sec)

3-         Pulses (one side as examiner ask & compare only femoral)

·           Abdominal aorta ( above umbilicus & just Lt to midline) - normally not felt

·           Femoral by 3 fingers (midinguinal point bet SP & ASIS in skin crease) (compare)

·           Popliteal: knee 160 degrees (relax muscles) fix knee by 2 thumbs & feel by rest of fingers meeting laterally in popliteal fossa (difficult & variable site)- be lat.

·           Posterior tibial: midway between med. malleolous & tendo-achilis

·           Dorsalis pedis:  lat. to ext. hallucis longus tendon on navicular bone –may be absent

4-                  Auscultations (over Femoral artery for bruit = stenosis) +/- carotid

I would like to finish my examination by:

1-         Performing ABPI.

2-               Examination of other pulses

Diabetic Foot

Introduce yourself

Exposure:  Upto groin

1-       Inspection as Ischemia (Color & Trophic changes, scars, Burger angle) +

·          Local amputation.

·          Charcot’s joint.

·          Signs of PN (Burns – injuries – Ingrowing toe nail).

2-         Palpation  Ask about pain  as Ischemia (TT, capillary refilling).

3-      Pulses  as Ischemia (Aorta, Femoral, Popliteal, Post. Tibial, dorsalis pedis).

4-      Sensation (PN) → stock hypothesia من تحت لفوق 

I would like to finish my examination by:

1      Performing ABPI (in DM > 1).

2-     Examination of other pulses

3-     Neurological examin. & fundus examin.

Ischemia UL

Exposure:  Upto groin & lower abdomen

1-                 Inspection من تحت لفوق

·          Color changes in sole (Pallor – Rubor – Cyanosis)

·           Trophic changes:  - Loss of Hair  - Brittle nails   - Nicotine stain (edge 2 adj.fingers)

- scar or Ulcer  (vasospastic ds) - Gangrene

2-         Palpation Ask about pain

·           TT (Temperature from distal to proximal & compare (very imp…) & Tenderness)

·           Capillary refill time: press on thumb away from nail ( Normal: 2-3 sec)

3-         Pulses (one side as examiner ask & compare only femoral)

·           Radial ( Lat. Fl.carpi radialis) 

·           Ulnar (Lat. Fl.carpi ulnaris)  

·           Brachial (Lat. biceps aponeurosis):

·           Posterior tibial: midway between med. malleolous & tendo-achilis

·           Subclavian (behind middle 1/3 clavicle)

4-       Special tests Allen’s test 1 & Addison test

5-       Auscultations (over carotid Fartery for bruit = stenosis)

1 Allen test: A test for integrity of the radial & ulnar arteries, pt. make a fist then the examiner compresses the patient's radial and ulnar arteries at the wrist. The patient is then asked to open and close the hand rapidly until the palm appears white. The examiner then releases either the radial or the ulnar artery and looks for return of pink colour and circulation to the hand. The test is then repeated releasing the other artery. Colour returns to pink 6 seconds if circulation through that artery is adequate. Compare radial & ulnar to determine dominant artery of hand

Post-Thrombotic Syndrome (PTS)

Introduce yourself

Exposure:  Upto groin

1-         Inspection

·          Inverted champagne bottle appearance (due to lipodermatosclerosis)

·          Ulcer: 3S FED SS → ulcer in gaiter area), …X… cm, edge sloping, floor (healthy / necrotic),…..

·          Signs Chr.Venous Insuffeciency around ulcer: Edema, Eczema, Hyperpigmentation,  Lipodermatosclerosis (area of subfascial fibrosis & ischemis), V.V.

·          Secondary Varicose Veins (need to be examined while standing later)

2-         Palpation Ask about pain

·          TT

·          Edema & level

·          Ulcer: TEBS (NEVER)

I would like to finish my examination by:

1-     Examination of Pulse & ABPI & sensation (exclude ischemic & neuropathic & mixed ulcer for priority of ttt)

2-     Examination for V.V. (while standing)

Varicose Veins Examination  (standing)

Introduce yourself

Exposure:  Upto groin  

1-         Inspection (standing)  لف قدامى

·      V.V. & its site (med. Side → LSV (long saph.v.) & lat. Side → SSV(short saph.v.)

·      Signs CVI (ulcer, pigmentation, eczema (purple), Lipodermatosclerosis¹)

·      Blow-out (site of perforator) (fascial defects)  

·      SFJ (= Saphina varix at skin crease) + thrill on cough  كح

·      Scar of previous oper. (leg – groin)

→☺”I can see dilated elongated tortuous veins on the -------aspect of the (leg/thigh) along the distribution of the (long/short) Saphenous venous system.  I can see also (Blow outs /Ulcer/Eczema/ lipodermatosclerosis 1) “

2-                 Palpation Ask about pain

·      TT (Temp. & Tenderness)             ·      Edemal & Level

·      Fascial defects (at sites of perforators) (Blow-outs) (Fegan test) 2

·      SFJ: feel thrill with cough → incompetent SFJ

·      Inguinal L.N. (vertical & horizontal groups)

☺” I am palpating the vein to feel the blow outs 2, the SF junction, cough please, I can feel a thrill, now will proceed to...”

3-                 Percussion (Tapping test)

4-                 Tests  

·       Tapping test 3 (percuss vein below by index & receive by index other hand) → +ve

·       Tourniquet test 4 see below

·       Doppler 5(SF junction – SP junction), examiner or u carry it (not pt.)- locate artery (midinguinal point below crease)- locate vein just 1 cm below & med. to artery – squeeze quadriceps (or ask pt. to cough)  → hear bidirectional flow → incompetent SFJ

I would like to finish my examination by:

1-     Auscultating over V.V. for bruit = AVF.

2-     Examination of Abdomen & PR (for 2ry V.V.)

3-     Exclude ischemia (examine pulse & ABPI)

1 Lipodermatosclerosis= skin changes due to Chronic venous hypertension = sclerosis of skin & subcutaneous fat by fibrin deposition , tissue death and scarring  

2 Blow-out= Fascial defect at site of perforator veins (which communicate between superficial & deep venous systems)

3 Tap test = Percuss the vein with one hand and feel the thrill with the other. Repaet on reverse  

4 Tourniquet test = Patient lies down, squeeze his L.L. to evacuate the veins, apply the tourniquet below the SF junction and make him stand up. Wait 30 secs If the vein doesn’t fill/fills slowly then the defect is from the SF junction, otherwise the defect is from the perforators. If partially controlled then ↑ = both SFJ & perforators.

5 Doppler = to asses SFJ incompetence→ Carried by examiner or in your pocket (not by pt.) - At site of thrill: Locate

                    artery (below skin crease) then vein just below &med. (1cm) - Squeeze quadriceps (punch of veins) or ask pt.

                    to cough  - Hear 2^nd sound (bidirectional flow)

                                    =  to asses SPJ incompetence (rare) - Flex knee (to relax muscles) - Locate artery in midline & vein lies beside

Surgical A-V fistula (spot diagnosis)

Introduce yourself

Exposure:  to elbow (area lymph drainage)

1-          Inspection

→ ☺”dilated pulsatile vessels in the forearm, with an overlying scar”

2-    Palpation  Ask about pain ”there is a thrill that can be felt, the distal limb is well perfused”

            ·      Feel synthetic material or loop graft  (only if examiner asked)    

                         

1-            Indications : Renal failure (for regular haemodialysis)

2-            Site: Upper Limb (start by non-dominant hand & distal first)

3-            Types

·             Direct: End to side (better) OR Side by side (venous hypertension)  

·             Bridge graft       a-  Autologous : Saphenous vein

                                        b-  Synthetic: PTFE

·             Loop graft

4-            Complications

·             Nerve injury (especially radial & median)

·             Infection (especially in synthetic)

·             Thrombosis & Occlusion

·             Steal phenomenon: Claudication due to inadequate perfusion

Lymphedema (spot diagnosis)

Introduce yourself

Exposure:  Upto groin

1-        Inspection

Lymphedema of LL because:

·         In dorsum of foot

·         Unhealthy skin & mottled (due to recurrent lymphangitis)

            (recurrent lymphangitis → obstructed lymphatics → ↑ lymphedema)

·         Preserved ankle crease            

·         +/- Fungal inf. (between toes)

2-      Palpation Ask about pain

·     Edema & level

·     Inguinal L.N.