Saturday, October 11, 2014

Peripheral Vascular Disease Examination

So here's how you examine a patient with vascular problem.

The principle : Inspection, Inspection, Inspection - Palpation, Percussion, Auscultation, Special Test.

As usual, before start examining, greet the patient, introduce yourself and examiner as well as ask permission. Expose the patient's whole lower limbs - because you are gonna check femoral pulse for arterial and saphenofemoral junction (SFJ) for venous. Stand at the end of bed and do general inspection.

ARTERIAL SYSTEM


Inspection

Asymmetry - muscle wasting (measure by using measuring tape) and evidence of amputation.

Colour - pale, pink or gangrene

Chronic sign of infection - dry, shiny and scaly skin, brittle nails, hair loss, infection in between toes, look under heels, lift up legs

Arterial ulcer - dry ulcer with no granulation tissue, usually located at dorsum of foot, punched out edge with sharp and well-defined margin


Palpation

Temperature - usually cold because of ischaemia

Capillary Refill Time - less than 2 seconds, pinch at big toe

Bone or joint tenderness

Pulse - start with femoral artery => popliteal => posterior tibial (just below medial malleolus) => dorsalis pedis (at the first web space, first bony prominence just lateral to extensor hallucis longus).


Auscultation

Bruit - for AV malformation


Special Test

Buerger's Test - patient lie supine, ask if there's pain, hold at ankle joint, lift up leg slowly and look if it turns pale, at how many degrees the leg is lifted up


Complete test

Do Ankle Brachial Systolic Index, doppler, carotid pulse, cardiovascular examination (source of embolism if any), neurological (check for sensation) and abdomen examination (aneurysm).

ps. Remember the 6Ps of acute limb ischaemia : Pain, Pallor, Perishingly Cold, Paraesthesia, Paralysis, Pulseless.


VENOUS SYSTEM


Inspection

Asymmetry - swelling of calf (DVT, cellulitis, chronic venous insufficiency)

Colour - pigmentation (lipodermatosclerosis)

Previous scars or healing ulcers

Venous ulcer - wet ulcer with granulation tissue, located at gaiter area (lower 1/3 of limb, usually above medial malleolus), sloping edge with irregular margin

Varicosity - ask patient to stand up because we want to see at the back of leg as well, site for varicose veins


Palpation

Varicosity - check until what level, palpate along the long and short saphenous veins 

Tenderness for phlebitis and Hardness for thrombosis

Cough impulse - feel at SFJ for incompetence


Auscultation

Bruit - in case of AV malformation


Special test

Tradelenburg Test - this test is to assess if SFJ valve is competent or not. Ask patient to lie supine, lift leg up and empty veins, locate and occlude SFJ, ask patient to stand and release occlusion at SFJ. Test is positive (SFJ incompetent) if when you occlude SFJ, there is no varicosity, and when you release, varicosity appears.

Multiple Tourniquet Test - apply tourniquet at the valves. Apply below SFJ, just above knee, just below knee and 5/10/15cm above medial malleolus.


Complete Test

Do abdomen and per rectal examination to check for mass. Do arterial system examination to check for mixed venous and arterial diseases. 

That's about all! Let's hope we can remember all of these points during exam!!

Good luck Good luck!! :D

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