PHYSICAL EXAMINATION
of the
VASCULAR SYSTEM
Hugh Gelabert, M.D.
Vascular Surgery Division
UCLA School of Medicine
Today’s Objective
• To review the examination of the
Vascular System
• To review exam techniques
• To discuss common findings
• To review the correlation between
patient symptoms and exam findings
Goal of Medical History
• To record the patient’s symptoms at
time of presentation.
• To organize the events which have lead
to presentation.
• To summarize the evidence which
supports diagnostic hypothesis.
• To provide basis and direction for care.
Goals of Physical Exam
• To record the state of patient’s health at
the time of the examination.
• To provide a longitudinal record of the
patient’s health.
• Allow assessment of progression of
disease.
• Allow prognostication of natural history.
• Allow recommendations for care.
Vascular Physical Exam
Arterial Anatomy
Goals
• establish presence and quality of pulses
• establish presence or absence of findings:
aneurysms, arterial bruit, signs of ischemia,
signs of venous disease
ARTERIAL ANATOMY
ARTERIAL ANATOMY
ARTERIAL ANATOMY
Vascular Physical Exam
Dorsalis Pedis
Posterior Tibialis
Vascular Physical Exam
Femoral Artery
Popliteal Pulse
Vascular Physical Exam
Aortic Aneurysm Exam
Vascular Physical Exam
Subclavian Artery Exam
Vascular Physical Exam
Carotid Artery Exam
Vascular Physical Exam
Bruit
• Sound made by vibrating arterial wall
• Caused by turbulent blood flow making
arterial wall vibrate
• Indicates the presence of an arterial
lesion
Vascular Physical Exam
Vascular Findings
• Generally related to
– Blockage of blood vessel
– Dilatation of blood vessel
• Subsequent events
– Ischemic tissue
– Gangrenous tissue
Vascular Physical Exam
Ischemia
• Decreased blood supply results in
metabolic compromise.
• Grades of severity reflect acuity of
condition as well as the magnitude of
the reduction in circulation.
• ACUTE vs CHRONIC
Vascular Physical Exam
Acute Ischemia
• 5 ‘P’s
– Pulseless
– Pain
– Pallor
– Paresthesia
– Paralysis
– Poikilothermia (Cold)
Acute Ischemia
Vascular Physical Exam
Acute Ischemia
• An abrupt disruption of the normal blood
supply to a vascular bed.
• Example:
•
•
•
•
Gunshot wound
Fracture
Tourniquette
Embollus
Vascular Physical Exam
Acute Ischemia
• Implies that without prompt restoration
of blood supply there will be significant
permanent damage to tissues.
• Susceptibility to Acute Ischemic Injury
– Nerve
+++
– Muscle
++
– Tendon and Bone +
Vascular Physical Exam
Chronic Ischemia
• A process where the gradual onset and
magnitude of ischemia has allowed the body
time to compensate for the decreased blood
supply.
• Key Concept: “Collateral Circulation”
• Compensation is never as good as original.
• The vascular bed survives with less blood.
Vascular Physical Exam
Chronic Ischemia
• Changes in the Limbs
– Skin …………………... Growth slowed
– Nails beds …………… Growth slowed
– Hair follicles
……. Lost
– Sebaceous glands …… Lost
• Result: Thin, dry, skin with loss of hair,
abnormal nail growth / fungal infections.
Vascular Physical Exam
Capillary Refill
• The time required for capillary system to refill
following compression of the nail bed or
finger pad.
• Normal should be rapid (1 sec or less)
• Decreased
–
–
–
–
Normal physiologic response (eg. cold)
Abnormal vasomotor tone (eg. Raynaud’s)
Acute Ischemia
Chronic Ischemia
Vascular Physical Exam
Capillary Refill
• In the chronic ischemic limb:
– Pallor on Elevation
• Insufficient arterial pressure to perfuse when
leg elevated above level of heart.
• Limb drains of blood.
– Dependent Rubror
• Blood pooling in maximally dilated capillary bed
• Cyanosis -- when blood is de-oxygenated
Tissue Refill
Venous Guttering
Buerger’s test
Vascular Physical Exam
Capillary Refill
• In Acute Ischemia
– Cyanosis noted because blood hemoglobin is
desaturated of oxygen
– Compression of digit results in evacuation of blood
from capillaries
– Refill of blood is sluggish because of decreased
arterial pressure.
– In severe cases the blood in capillaries may
thrombose and will not blanch on palpation
Cyanosis with acute ischemia
Vascular Physical Exam
Ulceration
• A discontinuity in the integrity of the skin
which persists despite sufficient time for
healing.
• Must be able to distinguish three types:
Arterial, Venous, Neuropathic.
Ulcers
Differential Presentation of Ulcers
Location
Symptoms
Outline
Assoc findings
Arterial
distal
painful
sharp
Art sx
no pulse
Venous
maleolar
+/irregular
CVI sx
OK pulse
Neuro
plantar
no pain
punched
other Dx
OK pulse
What kind of ulcer ?
Neuropathic
Plantar
location
Punched
Out
margins
Insensate
What kind of ulcer ?
Arterial Ulcer
Distal
location
Sharp
margins
Painful
What kind of ulcer ?
Venous Ulcer
Maleolar
location
Irregular
margins
Insensate
or Painful
Ulcers
VENOUS
DIABETIC
ARTERIAL
Gangrene:
Necrosis or death of tissue.
Decubitus Eschar
Vascular Physical Exam
Gangrene
• Death of tissue
– Related to absent blood supply
– Infections
– Tissue Toxins
– Radiation, Trauma
• WET Gangrene vs DRY Gangrene
– Bacterial superinfection
– Mumefaction or mumyfication
Wet Gangrene
Dry Gangrene
Gangrene
A dynamic process develops
where tissues becomes ischemic
with acute necrosis, autolysis and
liquefaction.
In the absence of superinfection
the tissue gradually dessicates
and becomes mummyfied. Later,
eschar separation and auto-amputation take place.
Blue Toe Syndrome
Digital Embolizationa
Vascular Physical Exam
Process of Auto Amputation
• Dry Gangrene of Digit
– Tissue dessicates
– Demaracation
– Eschar separation
– Epidermal ingrowth
– Wound margin contraction
– Osteolysis
Auto-amputation
Vascular Physical Exam
Methods:
Prepare your patient for exam:
•
•
•
•
be sure room temperature is correct
be sure limb position is as needed
be sure privacy is respected
place patient in correct position: supine on
exam table is generally best
• uncover area to be examined
Vascular Physical Exam
Methods:
Discuss what you are about to do
• inform patient of intention of
examination
• explain how exam will be conducted
Vascular Physical Exam
Methods:
Prepare Yourself for the Exam
• approach exam systematically
• compare bilaterally
• review patient complaints as exam
progresses
Vascular Physical Exam
Methods:
Follow Exam Sequence
•
•
•
•
•
observe
auscultate
lightly touch
palpate
compress
Vascular Physical Exam
Specific Observations
PULSES
-- should note 17 pulses.
-- quality (-, +, ++)
Temporal
Carotid
Brachial
Radial
Aorta
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibialis
x2
x2
x2
x2
x1
x2
x2
x2
x2
Vascular Physical Exam
Specific Observations
ANEURYSMS
-- should examine for 5 aneurysms
Aorta
x1
Femoral x2
Popliteal x2
Vascular Physical Exam
Specific Observations
BRUIT
-- should listen for 5 bruit.
Carotid
x2
Aorta
x1
Femoral x2
Vascular Physical Exam
Specific Observations
SIGNS OF ISCLEMIA
-- look for 6 Ischemic Signs in each limb.
Color
Capillary Refill
Eschar
Temperature
Ulceration
Location
Vascular Physical Exam
Specific Observations
VENOUS SIGNS
-- look for 5 Venous Signs in each limb
Brawny Color
Ulceration
Location
Varicose Veins
Edema
Vascular Physical Exam
Evidence Testing
•
•
•
•
•
•
Scenario #1: Patient complains of calf claudication
Scenario #2: Patient complains of thigh claudication
Scenario #3: Patient complains of buttock claudication
Scenario #4: Patient complains of leg swelling
Scenario #5: Patient complains of cold feet
Scenario #6: Patient complains of pulsatile mass in abdomen
Evidence Testing
• Scenario #1:
Patient complains of calf claudication
• Consider that the ischemic symptom develops in the
affected muscle bed.
• The affected muscle bed lies downstream from the
causative lesion.
Evidence Testing
• Scenario #1:
Patient complains of calf claudication
• Femoral pulses would be present
• Distal (DP / PT) would probably be absent
• Popliteal pulses may be present, but more commonly
the arterial lesion is in the SFA and the popliteal pulse
is absent.
• Distal signs of chronic ischemia would be present
Vascular Physical Exam
Examination Instrument
Student Worksheet -- Specific Observations
4. Ischemic Signs -- signs of arterial disease.
(normal, abnormal; yes, no; If yes, location)
1. Pulses -- should note quality (-, +, ++)
right
_____
_____
_____
_____
_____
_____
_____
_____
left
_____
_____
_____
_____
_____
_____
_____
_____
_____
Superficial Temporal
Common Carotid
Brachial
Radial
Aorta
Common Femoral
Popliteal
Dorsalis Pedis
Posterior Tibialis
2. Aneurysms (yes, no)
right
_____
_____
left
_____
_____
_____
Aorta
Common Femoral
Popliteal
left
_____
_____
_____
Common Carotid
Aorta
Common Femoral
3. Bruit (yes, no)
right
_____
_____
right
_____
_____
_____
_____
_____
left
_____
_____
_____
_____
_____
Color
Temperature
Capillary Refill
Ulceration
Eschar
Location
5. Venous Signs -- signs of venous disease.
(yes, no. If yes, location)
_____
_____
_____
_____
_____
_____
_____
_____
Brawny Color
Varicose Veins
Ulceration
Edema
Location
Conclusion
•
•
•
•
Reviewed the Vascular exam
Reviewed exam techniques
Discussed common findings
Discussed relation between patient
symptoms and exam findings
• Next step … Med West
Vascular Physical Exam
PE Module -- Organization
•
•
•
•
•
Med West clinical examination facility
exam rooms available today
model patients
All normal exams
Goal: Practice normal exam on different
patients
• Goal: Practice self-evaluation
Vascular Physical Exam
PE Module -- Organization
•
•
•
•
•
•
34 students
8 model patients
Students subdivide into Groups of 4
4 patient exams per Group
Groups rotate exam every 20 min
Assemble at end for discussion
Vascular Physical Exam
Examination Instrument
Student Worksheet -- Specific Observations
4. Ischemic Signs -- signs of arterial disease.
(normal, abnormal; yes, no; If yes, location)
1. Pulses -- should note quality (-, +, ++)
right
_____
_____
_____
_____
_____
_____
_____
_____
left
_____
_____
_____
_____
_____
_____
_____
_____
_____
Superficial Temporal
Common Carotid
Brachial
Radial
Aorta
Common Femoral
Popliteal
Dorsalis Pedis
Posterior Tibialis
2. Aneurysms (yes, no)
right
_____
_____
left
_____
_____
_____
Aorta
Common Femoral
Popliteal
left
_____
_____
_____
Common Carotid
Aorta
Common Femoral
3. Bruit (yes, no)
right
_____
_____
right
_____
_____
_____
_____
_____
left
_____
_____
_____
_____
_____
Color
Temperature
Capillary Refill
Ulceration
Eschar
Location
5. Venous Signs -- signs of venous disease.
(yes, no. If yes, location)
_____
_____
_____
_____
_____
_____
_____
_____
Brawny Color
Varicose Veins
Ulceration
Edema
Location
Vascular Physical Exam
Assessment Instrument
Did the student examine and record the following?
YES
_____
_____
_____
_____
_____
NO
_____
_____
_____
_____
_____
17 pulses
5 aneurysms
5 bruit
6 sings of arterial disease
5 signs of venous disease
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
explain examination procedure
position patient correctly
uncover the skin of the part to be examined.
inspect
auscultate with stethoscope on skin
touch skin (no through clothing or dressing)
palpate for aortic aneurysm between umbilicus and xyphoid
palpate for popliteal pulse or aneurysm with two hands
stand at foot of patient while palpating dorsalis pedis and posterior tibial
_____
_____
_____
_____
_____
_____
compress ankle to assess edema
feel toes to asses temperature
press toes to asses refill
Totals: _____
_____