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Surgery 6th year, Tutorial (Dr. Aram Baram)
I examined this patient's peripheral vascular system. On inspection from the end of the bed, the patient appeared comfortable at rest with no signs of vascular disease. Both limbs were pink and well perfused with normal capillary refill times. All pulses were present and equal bilaterally. Buerger's test was negative. To complete my examination, I would assess the cardiovascular system and test the relevant muscles and nerves of the affected limb, and perform duplex scans and ankle-brachial pressure indexes.
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Surgery 6th year, Tutorial (Dr. Aram Baram)
- 1. Peripheral Vascular Examination By Doctor Aram Baram MD,MRCSEd 1
- 3. Introduction ▪Smile, look patientin the eye, shake hands, say your name and explain (in non technical terms) what you are about to do! ▪Obtain adequate exposure –clothes removed above the waist (bra may be left on) ▪Position patient correctly –patient lying supine with upper body at ~ 45 degrees 3
- 4. General Inspection (cont.) Fromthe end of the bed take note of: ▪Any special aids, devices, drugs or instructions around the bedside ▪Look at sputum mug contents –amount & consistency –mucoid, mucopurulent, purulent, blood- stained ▪Check temperature chart –febrile above 380 4
- 5. General Inspection (cont.) ▪Firstask yourself a very important Q … how sick does the patient look? ▪Assess rate & depth of respiration, breathing pattern at rest 5
- 6. Vascular System Components ▪Arteries ▪ Veins – Deep veins of the legs carry 90% of venous return from the lower extremities – Superficial include great saphenous , small saphenous and communicating veins ▪ Lymphatics and lymph nodes – Only cervical, supraclavicular, axillary, arm and leg nodes palpable 6
- 7. Peripheral Vascular Exam ▪Upper limbs – Size, symmetry, skin color, temp., edema – Capillary refilling – Subclavian, Axillary, Brachial, Ulnar and Radial pulses – Allen‟s test (radial and ulnar patency), venous filling ▪ Legs – Size, symmetry, skin color, temperature – Femoral pulse, bruit and inguinal lymph nodes – Popliteal, DPA and PTA pulses, – Peripheral edema, ulcers/lesions 7
- 8. Introduction ▪ Introduce yourself ▪Ask Permission to examine ▪ Expose the patient lower limbs and upper limbs ▪ Ask the patient if they have any pain 8
- 9. Stand at theend of the bed STOP Look for a few seconds Show you are looking around the bed Oxygen Inhalers Catheters Drains Fluids Dressings Position Comfortable? 9
- 10. LOOK… ▪ Stand atthe end of the bed • Colour of the Limbs (pale/blue/black) • Hair Loss • Ulcers • Scars • Muscle Wasting 10
- 11. LOOK... ▪ Move Closer(pressure areas) • Lateral side of the foot • Head of first metatarsal • Heel • Both Malleoli • Tips of the Toes ▪ Look in between each of the toes 11
- 12. FEEL… ▪Run the backof your hand down both limbs ▪Compare both sides ▪Warm or cold? ▪Point of change? ▪Capillary Refill time ▪Pulses 12
- 13. PULSES... ▪ Upper limb Subclavain, Carotid, Brachial, Radial, Ulnar, Allen‟s test, Cappillary re-filling ▪ Lower Limb – Aorta – Femoral (mid inguinal point) – Popliteal 3 methodes feel with 8 fingertips!! – Posterior tibial – Dorsalis Pedis – Anterior tibial 13
- 14. Pulse Points 14
- 15. LISTEN... ▪Bruits at the Aorta, Iliac and Femoral arteries ▪Subclavian and Carotid Arteries 15
- 16. There are severalsystems for grading the amplitude of the arterial pulses. ▪4+ Bounding ▪3+ Increased ▪2+ Brisk, expected ▪1+ Diminished, weaker than expected ▪0 Absent, unable to palpate 16
- 17. Radial pulse… ▪ Palpatethe radial pulse with the pads of your fingers on the flexor surface of the wrist laterally. ▪ Patient‟s wrist better to be in neutral position, may help you feel this pulse. ▪ Compare the pulses in both arms 17
- 18. Brachial pulse… Flex thepatient‟s elbow slightly, and with the thumb of your opposite hand 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. 18
- 19. Subclavian artery… ▪Palpable less frequently ▪Audible often 19
- 20. Carotid Arteries… At thelevel of thyroid cartilge Opposite to the mid third of the sternoclidomastoide It may be visible just medial to the sternomastoid muscles. 20
- 21. Abdominal Aorta… Is anupper abdominal, retroperitoneal structure which is best palpated by applying firm pressure with the flattened fingers of both hands to indent the epigastrium toward the vertebral column. In extremely obese individuals or in those with massive abdominal musculature, it may be impossible to detect aortic pulsation. Auscultation should be performed over the aorta and along both iliac vessels into the lower abdominal quadrants. 21
- 22. Femoral Pulse… ▪ Thecommon femoral artery emerges into the upper thigh from beneath the inguinal ligament , 1-2 inches below the mid point symphysis pubis to the anterior superior iliac spine. ▪ It is best palpated with the examiner standing on the ipsilateral side of the patient and the fingertips of the examining hand pressed firmly into the groin. ▪ Auscultation should be performed in this area, as well. 22
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- 24. Popliteal Artery… It maybe difficult or impossible to palpate in obese or very muscular individuals. Generally this pulse is felt most conveniently with the patient in the supine position and the examiner's hands encircling and supporting the knee from each side. The pulse is detected by pressing deeply into the popliteal space with the supporting fingertips. Since complete relaxation of the muscles is essential to this examination, the patient should be instructed to let the leg "go limp" and to allow the examiner to provide all the support needed. 24
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- 27. The posterior tibialpulse… The posterior tibial artery lies just posterior to the medial malleolus. It can be felt most readily by curling the fingers of the examining hand anteriorly around the ankle, indenting the soft tissues in the space between the medial malleolus and the Achilles tendon, above the calcaneus. The thumb is applied to the opposite side of the ankle in a grasping fashion to provide stability. Again, obesity or edema may prevent successful detection of the pulse at the location. 27
- 28. The Dorsalis PedisArtery Is examined with the patient in the recumbent position and the ankle relaxed. The examiner stands at the foot of the examining table and places the fingertips transversely across the dorsum of the forefoot near the ankle. The artery usually lies near the center of the long axis of the foot, lateral to the extensor hallucis tendon but it may be aberrant in location and often requires some searching. This pulse is congenitally absent in approximately 10% of individuals. 28
- 29. Bruits… After palpating theartery, auscultation for a bruit should be performed. Bruits are detected by auscultation over the large and medium-sized arteries (e.g., carotid, subclavain, brachial, abdominal aorta, femoral) with the diaphragm of the stethoscope using light to moderate pressure. Excessive pressure may produce, intensify, or prevent a bruit from being detected by indenting the vessel wall or occluding blood flow in the artery. One should listen over the artery after palpation of the artery to avoid overlooking a significant lesion. 29
- 30. Bruits… ▪ Occasionally, bruitsare audible over the upper abdomen in young, healthy individuals. ▪ These sounds apparently originate from tortuous vessels and are of no clinical significance; if the subject has a normal blood pressure and is free of abdominal symptoms, such findings may be disregarded. ▪ Frequently the examiner will detect a "thrill" or palpable vibratory sensation over a vessel in which a loud bruit is audible. ▪ The thrill is indicative of marked turbulence in local blood flow and suggests significant vascular pathology. ▪ If a thrill is noted during examination of the pulses, it should be recorded in the appropriate space on the data base. 30
- 31. FURTHER TESTS... ▪ Elevateto 15 degrees ?venous guttering ▪ Elevate leg further. Note angle at which turns pale (BUERGER‟S ANGLE) ▪ Ask patient to hang their leg over the edge of the bed (BUERGER‟S TEST) White Pink Flushed purple-red (Reactive Hyperaemia) 31
- 32. THEN ▪ Cover thepatient up & thank them ▪ Turn to the examiner and present your findings….. 32
- 33. Formulate Your Presentation Iexamined this elderly gentleman‟s peripheral vascular system. On inspection from the end of the bed he appeared comfortable at rest with no peripheral signs of vascular disease. Both limbs were pink and well perfused with capillary refill time < 2secs. All pulses were present and equal on both sides. Buerger‟s test was negative. 33
- 34. TO COMPLETE MY EXAMINATION….. ▪I would like to examine the rest of the peripheral vascular system including the cardiovascular system ▪ Test the relevant muscles and nerves of the affected limb ▪ Perform a duplex scan and ABPI‟s 34
- 35. Venous examination ▪ INSPECTION: ▪ General Appearance: ▪ Veins –Distribution / Size / Size of and visible sc veins ▪ Varicose Veins are by definition dilated and tortuous. ▪ Compare size of both legs esp at ankle level for evidence of oedema. ▪ Venous Stars – minute veins radiating from a single feeding vein. ▪ Skin – Inspect the skin of the whole leg but particularly the lower medial third since venous dx affects this area first, causing Pigmentation / Eczema and Ulceration. ▪ Signs of Chronic Venous Insufficiency – lipodermatosclerosis = ▪ Ulcers - 35
- 36. Palpation Fascial Defects -Feel along course of veins (Note tension in vein) and any tender fascial defects (usually at 5, 10 and 15 cm above medial malleolus) Pitting Oedema Sc Tissues - Thickening and tenderness Vein - Press on vein from above noting presence of retrograde flow Cough impulses - over saphenofemoral and saphenopopliteal junctions 36
- 37. Palpation... TRENDELENBERG TEST: Ask thepatient to lie down & raise the leg to empty the veins. Place 2 fingers ove the spahenofemoral junction. Ask the patient to stand up. If the veins remain empty while standing, the saphenofemoral junction is incompetent. Release pressure at the junction to see! NB. “This test is unreliable, so I would perform a Doppler Assessment as an alternative”. 37
- 38. Palpation... ▪TOURNIQUET TESTS: ▪ PatientSupine with Leg elevated ▪ Sweep veins empty (Note how easily the veins empty - may give signs of occlusion / compression). (if fail to empty this suggests high pressure within them) ▪ First place a tourniquet around upper third of thigh to occlude superficial veins ▪ Now, Patient Standing ▪ If veins above tourniquet distend - Saphenofemoral Junction is incompetent ▪ If veins below tourniquet fill there must be a perforator below level of tourniquet therefore once again elevate the leg and repeat the procedure with the tourniquet at a lower position on leg. ▪ (Note: Alternatively – one can use multiple tourniquets and simply release them sequentially) 38
- 39. AUSCULTATION: ▪Venous Clusters -may represent AV fistula ▪Thank the patient & turn to the examiner to present your findings 39
- 40. I examined…… I examinedthis ladies venous system of her lower legs. On general inspection there were varicosities in the distribution of the long saphenous vein of the right leg. There was no evidence of haemosiderin deposits or ulceration. Trendelenburgs test revealed incompetence at the saphenofemoral junction 40
- 41. TO COMPLETE MYEXAMINATION ▪I would like to ▪Examine the abdomen ▪Perform a DRE ▪A pelvic examination/examine the external genitalia 41
- 42. Thoracic cage -bony landmarks ▪ Clavicle; A-C joint; S-C joint ▪ Sternal angle; QuickTime™ and a xiphisternum; Video decompressor are needed to see this picture. sternal notch ▪ Rib counting using sternal angle as key landmark 43
- 43. Thoracic Muscles 1. pectoralis minor 2. pectoralis major 3. deltoid 4. rectus abdominus 5. external oblique (interdigitating with serratus anterior) 44
- 44. Surface Projections ▪ midline ▪ mid-clavicular line – midway between sternoclavicular joint & acromioclavicular joint ▪ anterior axillary line 45
- 45. Surface Projections ▪ Anterior axillary line – anterior fold of pectoralis major ▪ Mid-axillary line ▪ Posterior axillary line – posterior fold of latissimus dorsi 46
- 46. Surface Projections ▪ midline ▪ medial scapular line ▪ paravertebral line 47
- 47. Respiratory System ▪ pleuralreflections & extensions ▪ surface projections of lungs ▪ fissures & lobes ▪ bronchopulmonary segments 48
- 48. Lung markings -Anterior ▪ during quiet respiration lungs at: rib 6 (mid-clavicular line) rib 8 (mid axillary line) rib 10 (paravertebral line) ▪ pleural reflections 2 ribs below at ribs 8, 10 & 12 ▪ horizontal fissure to 4th costal cartilage ▪ oblique fissure to 6th costal cartilage 49
- 49. Lung markings -Posterior ▪ oblique fissure begins posteriorly opposite 3rd thoracic spinous process ▪ oblique fissure divides lungs into upper and lower lobes ▪ note how high the lower lobe of each lung extends! 50
- 50. Lung Surface Projections- Lateral 51
- 51. Bronchopulmonary Segments 52
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- 53. Routine CXR ▪ normal ▪ cardiac shadow ▪ bronchial tree ▪ lung & pleura ▪ ribs – anterior – posterior 54
- 54. the not so„routine‟ CXR ... right upper lobe consolidation left pleural effusion 55
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