The Peripheral Vascular Exam and Expanded Lymph Exam

Lymphatic system

extensive vascular network that drains lymph from body tissues and returns it to venous circulation

Lymph nodes

round, oval, or bean-shaped structues, vary in size according to location

What does the lymph system have an important role in?

immune system, cells in lymph nodes engulf cellular debris/bacteria and produce antibodies

Which lymph nodes are accessible to physical exam?

superficial lymph nodes

Common or concerning HPI symptoms

- pain or weakness in arms/legs

- intermittent claudication

- cold, numbness, pallor in legs, hair loss

- abdominal, flank or back pain

- color change in fingertips or toes in cold weather

- swelling with redness or tenderness (calves, legs, or feet)

Claudication

pain or cramping in the legs or extremities during exertion that is relieved by rest within 10 minutes

What PMHx may indicate the necessity for PV/Lymph exam?

- cardiac surgery or hospitalization

- chronic illness (HTN, bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction, stroke, vasculitis, thrombosis, TIA, CAD, Afib, dysrrhythmias)

What FamHx may indicate the necessity for PV/Lymph exam?

- AAAs in first-degree relatives (15-28%)

- Hx of clotting disease

- Connective tissue disorders

- PVD

What social Hx may indicate the necessity for PV/Lymph exam?

smoking

What are the characteristics to note when palpating peripheral pulses?

- rate & rhythm

- pulse contour (waveform)

- amplitude (force)

- symmetry

- obstructions

- variations

Grading of Pulses

3+ = bounding, increased

2+ = brisk, normal

1+ = diminished, barely palpable

0 = non palpable/absent

Arm exam (inspection)

inspect from fingertips to shoulders bilaterally (size, symmetry, swelling, venous pattern, color of skin)

Arm exam (palpation)

- radial pulse (wrist partially flexed)

- brachial pulse (flex elbow slightly, medial to biceps tendon)

What lymph nodes are assessed during the arm exam?

Epitrochlear nodes & Axillary nodes

How to palpate epitrochlear nodes

- Flex elbow to 90 degrees

- support forearm

- Feel in the groove between the biceps and triceps

- 3cm above medial epicondyle

How to palpate axillary nodes

support arm, cup fingers together, reaching as high as you can toward apex, behind pectoral muscles, slide down against chest wall (palpate along the inner and upper arm in the same fasion)

What is a normal capillary refill time in the arm exam?

<2 seconds

Leg exam (inspection)

size, symmetry, swelling, skin color, venous pattern (varicosities), hair patterns (loss?), skin changes (ulcerations)

Leg exam (palpation)

- femoral pulse (press deeply below the inguinal ligament, midway between the anterior and superior iliac spine and the symphysis pubis)

- popliteal pulse (flex knee some, leg relaxed; place fingertips of both hands to meet midline behind knee and press deeply into popliteal fossa)

- dorsalis pedis pulse (feel dorsum of foot, lateral to extensor tendon of great toe)

- posterior tibial pulse (curve fingers behind and slightly below medial malleolus of ankle)

What lymph nodes are assessed during the leg exam?

inguinal lymph nodes

How to palpate inguinal lymph nodes

Note size, consistency, borders, and tenderness

What type of inguinal lymph nodes are palpable in the normal patient?

nontender, discrete, inguinal nodes up to 1cm or 2cm

What is a normal capillary refill time in the leg exam?

<2 seconds

What else should you assess in the leg exam?

- varicositites

- temperature of feet and legs

Varicosities

dilated and tortuous veins, walls may feel thickened

What is important to check for when assessing the temperature of feet and legs?

Reflex Sympathetic Dystrophy (now called Complex Regional Pain Syndrome)

What is edema classically seen with?

venous issues (NOT arterial issues)

How do you assess for pitting edema?

press firmly but gently with thumb for at least 2 seconds (dorsal foot -> behind medial malleolus -> shins)

1+ pitting edema

2mm depression, barely detectable, immediate rebound

2+ pitting edema

4mm deep pit, a few seconds to rebound

3+ pitting edema

6mm deep pit, 10-12 seconds to rebound

4+ pitting edema

8mm very deep pit, >20 seconds to rebound

How to assess for unilateral swelling

Measure calves 10cm below the tibial tuberosity; the difference is usually <3 cm

What might venous tenderness or cords be seen with?

DVT (does not rule it out)

Homan Sign

Discomfort of the calf with forced dorsiflexion on the foot, evaluates for DVT

What is the purpose of the Allen Test?

Evaluate arterial perfusion of the hand; compare the patency of the ulnar and radial arteries

When should you perform the Allen Test?

before ABGs

What is a positive Allen Test?

Persisting pallor, indicating occlusion of the ulnar artery or its distal branches

How do you assess postural color changes of chronic arterial insufficiency?

Buerger Test

Buerget Test

Raise both legs about 90 degrees for up to 2 minutes until there is maximal pallor of the feet (expect to see normal color or slight pallor; marked pallor on exam suggests arterial insufficiency). Then, move the patient to a seated position with legs dangling (expect to see a return of color in about 10 seconds or less, with filling of the veins of the feet and ankles).

Peripheral Artery Disease "definition"

stenotic, occlusive, and aneurysmal diseases of the aorta, its visceral arterial branches, and branches to the extremities, excluding the coronary arteries

Peripheral Artery Disease (PAD)

atherosclerotic disease distal to the aortic bifurcation

How many Americans does PAD affect?

8 million Americans

What makes the prevalence of PAD increase?

age

Why do we care about PAD?

marker for cardiovascular morbidity and mortality, indicator of functional decline

PAD Risk Factors

- > 65 years old

- > 50 if the patient has a history of smoking or diabetes

- Leg symptoms with exertion

- Non-healing wounds

PAD Hx Screening

- smoking hx (past or present)

- diabetes

- HTN

- hypercholesterolemia

- CAD

- African American

PAD warning signs

- pain that limits walking or exertion in the legs, improves with rest

- poorly healing or non-healing wounds (look at feet and ankles)

- pain when at rest or pain intensity changes upon standing or lying

- abdominal pain after meals

- family hx of AAA

How do we screen for PAD of a lower extremity?

Ankle-Brachial Index (ABI) (high specificity, low sensitivity)

What is the initial treatment for PAD?

supervised exercise programs, smoking cessation, control of DM/HTN/cholesterol, foot care

Where can ABI be performed?

office setting

What does ABI detect?

stenosis of 50% or more in major vessels of legs

How do you perform ABI?

Measure SBP (with Doppler ultrasonography) in each arm and in pedal pulses, calculate reading for right and left (divide ankle pressure by arm pressure)

Normal ABI

0.90-1.30

ABI (mild to moderate disease)

0.41-0.90

ABI (severe disease with critical stenosis)

0.00-0.40

What Hx may indicate chronic arterial insufficiency?

intermittent claudication, progressing to pain at rest

Mechanism of chronic arterial insufficiency

tissue ischemia

Exam findings for chronic arterial insufficiency

- pulses decreased or absent

- pale on evaluation, dusky red dependency

- cool temperature

- thin, shiny, atrophic skin, loss of hair over foot and toes, thickened and ridged nails

- ulcerations can be seen at toes or points of trauma

- may develop into gangrene

In which patients may atherosclerotic renal artery disease be seen in?

patients with end-stage renal disease, CHF, co-occurring HTN and diabetes and other atherosclerotic disease

When should you suspect renal artery disease?

- HTN < 30 years old

- severe HTN > 55 years old

- accelerated, resistant, or malignant HTN

Screening for Renal Artery Disease

duplex ultrasonography, MRA or CTA of bilateral renal arteries

Abdominal Aortic Aneurysm

infra renal AA with diameter > 3 cm

When is an AAA at risk of rupture?

> 5.5 cm

Why is early detection of AAA key?

rupture can cause sudden death

AA Risk Factors

- male

- smokers

- HTN

- > 65 years old

- family hx

- CAD, PAD, and high cholesterol

Screening for AAA

US screening of men aged 65-75 years who have smoked more than 100 cigarettes in a lifetime

Where does arterial insufficiency occur?

in toes, feet, or possibly areas of trauma

What does the surrounding skin show in arterial insufficiency?

callus or excess pigmentation

Describe the pain associated with arterial insufficiency

Pain is often severe, unless marked by neuropathy

Associated symptoms (arterial insufficiency)

decreased pulses, gangrene

What causes acute arterial occlusion?

embolism or thrombus

How does acute arterial occlusion present?

Distal pain, usually involving foot and leg (sudden onset). Exam reveals cool, numb, weak limb with absent distal pulses.

What causes chronic venous insufficiency?

Chronic obstruction and incompetent valves in the deep venous system

How does chronic venous insufficiency present?

- Edema is soft, pitting, and occasionally bilateral

- Brawny changes (reddish, brown, purple, or ashen patches of skin)

- Skin texture changes (first dry scaly, then thickened and leathery)

- Ulceration in more advanced stages

What causes venous stasis dermatitis?

Weakened vein valves cause blood to pool in the legs, leading to fluid leakage into interstitial spaces, swelling, itching, and discoloration

Lipodermatosclerosis

dry, scaly, itchy, or thickened, leathery skin (associated with venous stasis dermatitis)

Treatment for venous stasis dermatitis

- elevation

- compression stockings

- emollient or Sarna

Advanced chronic venous insufficiency - is it painful?

yes

Advanced chronic venous insufficiency - mechanism?

venous stasis and hypertension

Advanced chronic venous insufficiency - appearance?

normal or cyanotic on dependency, brown pigmentation appears in chronic cases

Advanced chronic venous insufficiency - temperature?

normal

Advanced chronic venous insufficiency - skin changes?

brown pigmentation around the ankle, stasis dermatitis and possible thickening of the skin, may cause narrowing of the legs as scar develops

Where are chronic venous insufficiency ulcers typically seen?

over the medial and lateral malleolus (medial more common)

What is a chronic venous insufficiency ulcer made of?

painful granulation tissue and fibrin

Describe the borders of a chronic venous insufficiency ulcer.

Irregular and flat

What is the pain range for chronic venous insufficiency ulcers?

mild discomfort to painful aching throbbing sensation

Where does neuropathic ulceration develop?

in pressure points and areas of diminihed sensation

Describe a neuropathic ulcer.

- surrounding skin is calloused

- no pain, if uncomplicated no gangrene

Neuropathic ulcer (associated symptoms)

decreased sensation and absent knee jerks

Raynaud's Phenomenon

episodic reversible vasoconstriction in the fingers and toes (distal portion of one or more fingers)

What is Raynaud's phenomenon usually triggered by?

cold

Other notes about Raynaud's Phenomenon

- pain is not prominent unless there are ulcerations

- brief, occurs over minutes

- Primary and Secondary manifestations

Superficial phlebitis

Inflammation of the superficial vein

How does superficial phlebitis present?

pain and tenderness along the course of a superficial vein, most commonly the saphenous system

What causes superficial phlebitis?

venous procedure

Treatment for superficial phlebitis

supportive care (NSAIDs/warm compresses)

Superficial Venous Thrombosis

when clot is confirmed by US, associated with increased risk of DVT/PE

Deep vein thrombosis (DVT)

thromboembolic disease of deep calf veins, popliteal, femoral, or iliac veins

Signs of DVT

painful, calf swelling with erythema