COMPLETE PHYSICAL EXAMINATION OF THE PVS Ask about:

§ Coldness, numbness, pallor in the legs/feet, ⇒ Decreased arter

daryllantipuesto&seffcausapin™
HAIR LOSS over ant. tibial surface. surface
There are several points to remember prior to beginning the PVS examination. These include: ⇒ Gangrene = “dr
1. Taking complete vital signs of the patient. Take BP in both arms.
2. Palpate carotid pulse, auscultate for bruits. PAD WARNING SIGNS:
3. Auscultate for aortic, renal and femoral bruits; palpate aorta, and determine maximal diameter. • Fatigue, aching, numbness, or pain that limits walking or exertion in the legs
4. Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial arteries. • Erectile dysfuntion
5. Inspect ankles and feet for color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin
• Poorly healing/ non healing wound of the lower ex
changes, hypertrophic nails.
6. Assessment of the peripheral vascular system relies primarily on inspection of the arms and legs, palpation of the • Any pain at rest
pulses, and a search for edema • Abdominal pain after meals
• First degree relatives with AAA

ANKLE BRACHIAL INDEX (ABI)

- reliable, reproducible, easy to perform
- Uses Doppler utz
Instructions:
1. Px rest in supine position in a warm room for at least 10mins before testing
2. Place bp cuffs on both arms and legs, then apply utz gel over BRACHIAL, DO
3. Measure SYSTOLIC pressures in arms
a. Use vascular Doppler to locate brachial pulse
b. Inflate at 20 mmhg above last audible pulse
c. Deflate slowly and record pressure at w/c PULSE BECOMES AUDIBLE
d. Obtain 2 measures in each arm then record average as the BRACHIAL
§ PERIPHERAL ARTERIAL DISEASE (PAD) – stenotic, occlusive, aneurysmal dis of the aorta, its visceral arterial
4. Measure systolic pressures in ANKLES
branches, and the arteries of the lower extremities, EXCLUSIVE of the coronary arteries
§ Age at risk = 50yrs or older and those w/ risk factors a. (same procedure as above)
7. Ask the following before starting the examination. b. Use dorsalis pedis pulse
GENERAL SURVEY RATIONALE/ SIGNIFICANT FINDINGS c. Repeat for post. Tibial arteries

Ask about: Interpretation:

§ Abdominal, flank or back pain? (esp in older ⇒ Abdominal Aortic Aneurysm (AAA)- expanding >0.90 (0.90-1.30) = NORMAL lower extremity blood flow
smokers) hematoma may cause s/sx by compression of the bowel, aortic
<0.89 - >0.60 = mild PAD
§ Constipation? branches or ureters
<0.59 - >0.40 = moderate PAD
§ Distention? <0.39 = severe PAD
§ Urinary retention? Diff voiding? Renal colic?
Ask about:
§ Pain or cramping in the legs DURING ⇒ sx limb ischemia w/ exertion
exertion, relieved by rest w/in 10mins = ⇒ pain w/ walking or prolonged standing, radiating from the
INTERMITTENT CLAUDICATION spinal area into the buttocks, thighs or lower legs/feet
ARMS PALPATION RATIO
INSPECTION RATIONALE/ SIGNIFICANT FINDINGS THE INGUINAL LN
BOTH arms from fingertips to shoulders. Note the ff: § Superficial inguinal nodes
• Size, symmetry, any swelling § lymphedema of arm and hand § Note size, consistency, discreteness, ⇒ Lymphadenopath
• Venous pattern § Venous obstruction = prominent veins in an edematous arm tenderness? WITHOUT tender
• Color of skin and nail beds, texture of skin § Raynaud’s disease = wrist pulses: NORMAL, sharply § Non- tender, discrete, up to 1cm-2cm are
demarcated pallor of fingers frequently palpable in NORMAL people
Femoral pulse
PALPATION RATIONALE/ SIGNIFICANT FINDINGS § press deeply below the inguinal lig., and § Partial or comple
about midway between the ASIS and symphysis pubis FEMORAL pulse
• Palpate RADIAL PULSE
§ Chronic arterial o
• Feel for BRACHIAL PULSE (if you suspect arterial
§ Aortic insufficiency = bounding carotid, radial, and femoral intermittent clau
insuff)
pulses § Femoral aneurys
◦ Feel for epitrochlear nodes
§ Arterial occlusion = asymmetric diminished pulses Popliteal pulse § Popliteal artery a
◦ These nodes are difficult or impossible to
identify in most normal people § px knee slightly flexed, legs relaxed pulse
§ if it cannot be felt, try w/ the px prone § Arteriosclerosis
GRADING OF PULSES circulation in the
◦ Femo
GRADE DESCRIPTION
◦ Poplit
3+ BOUNDING
Dorsalis pedis pulse § absent pedal pu
2+ BRISK, EXPECTED (NORMAL)
§ dorsum of foot just lateral to the extensor tendon
1+ DIMINISHED, WEAKER THAN EXPECTED of the big toe
0 ABSENT, UANBLE TO PALPATE Posterior Tibial artery § Sudden arterial o
§ curve fingers behind and slightly below the medial limb distal to the
LEGS malleolus ◦ EMER
INSPECTION RATIONALE/ SIGNIFICANT FINDINGS
BOTH LEGS from the groin—buttocks—feet. Note the
ff: § Cellulitis- warmth and redness over calf
EXAMINATION OF THE PERIPHERAL VEIN
INSPECTION RATIO
• Size, symmetry, swelling
• Venous pattern, venous enlargement • Look for edema
• pitting edema (use thumb, at least 2 seconds) § Bilateral edema
• Pigmentation, rashes, scars, ulcers
ü over dorsum of each foot syndrome
• Color and texture of the skin, nail beds distribution
ü behind each medial malleolus § Deep iliofemoral
of hair on the lower ex
ü over the shins tenderness in th
• Temp of feet and legs (use back of fingers)
• swelling: unilateral or bilateral? § Chronic venous
• Venous tenderness that may accompany DVT? just above the m
• Color of skin § Varicose veins =
• Redness? o Brownish areas near the ankles? o §
Ulcers?
MEASURING EDEMA Mapping of Varicose Veins
1. With the use of flexible tape, measure the: • Px standing, place palpating fingers gently on a
a. Forefoot vein, w/ the other hand below it and compress the
b. The smallest possible circumference above the ankle. vein sharply
c. The largest circumference at the calf.
◦ Feel for a pressure wave
d. The mid- thigh
◦ A palpable pressure wave indicates that
2. A difference of more than 1cm just above the ankle or 2 cm at the calfs’ unusual in normal people and suggest edema.
2 parts are connected
Possible causes of edema in PVS: EVALUATING THE COMPETENCY OF VENOUS VALVES
1. Recent DVT TRENDELENBURG TEST (retrograde filling)
2. Chronic venous insufficiency from previous thrombosis or incompetence of the valves - Can assess valvular competency in both the
3. Lymphedema communication veins and the saphenous system
• Px supine ü Incompetent valv
• Elevate one leg to about 90 deg to empty it of filling of the sup
venous blood occluded
SPECIAL TECHNIQUES • Occlude the great saphenous vein in the upper ü Incompetent val
TEST RATIONALE/ SIGNIFICANT FINDINGS thigh additional filling
ALLEN’S TEST • Ask the px to stand
• Ensure patency of the ulnar artery before § Acute Embolic occlusion, Buergers’ dse, Thromboangiitis • NORMALLY: saphenous vein fills FROM BELOW
puncturing the radial artery for blood sample obliterans- absent or diminished wrist pulses (about 35 sec)
collection § Arterial insufficiency = marked pallor on elevation in allen test • After px stands for 20sec, release compression
• Ask px to make a fist with one hand and look for sudden additional venous filling =
• Compress both radial and ulnar arteries firmly NORMALLY THERE IS NONE
• Ask px to open hand into a relaxed, slightly flexed
position
• PALM IS PALE
• Release pressure over ULNAR artery
• If the ulnar artery is patent, PALM FLUSHES
WITHIN about 3 to 5 SECONDS
POSTURAL COLOR CHANGES OF CHRONIC ARTERIAL
INSUFFICIENCY
• Raise legs to about 60 degrees until maximal
pallor of the feet develops (w/in 1 min)
• Ask px to sit up w/ legs dangling down, compare
both feet:
◦ Return of pinkness of skin (N= 10 sec
or less)
◦ Filling of veins of the feet and ankles (N
= 15 seconds)
• Look for any unusual rubor (dusky redness) =
persistence means art. insufficiency