PCM Peripheral Vascular and Lymphatics Overview

Peripheral Vascular and Lymphatics Overview

Instructor Information

  • Instructor: Ann Trawick, D.O.

  • Position: Assistant Professor of Primary Care Medicine

  • University: Rocky Vista University College of Osteopathic Medicine

  • Resource: 3D4Medical.com, LLC (2016) Essential Anatomy 5 (Version 5.0.2)

Learning Objectives

  • Anatomic Identification

    • Identify the anatomical location of peripheral arteries, veins, and lymph nodes discussed in class.

  • Physical Examination Findings

    • Describe important physical examination findings for:

    • Peripheral arteries

    • Veins

    • Lymphatics

  • Common Symptoms

    • Describe common presenting symptoms of:

    • Peripheral artery disease

    • Venous disease

    • Lymphatic disease

Peripheral Vascular and Lymphatic Exam
Screening Exam:

  • Inspection of upper and lower extremities including:

    • Ulceration

    • Color of the skin

  • Palpation for:

    • Edema (graded)

    • Skin texture

    • Skin turgor

    • Skin temperature

    • Pulses (graded)

    • Lymph nodes

  • Auscultation: Check for bruits in:

    • Carotid arteries

    • Abdominal aorta

    • Renal arteries

    • Iliac/Femoral arteries

  • Special Tests include:

    • Allen test

    • Roos test

    • Adson's test

    • Ankle Brachial Index (ABI)

    • Homan's sign

    • Postural color change test

Key Vocabulary and Notable Metrics

  • Total number of capillaries in the body: approx. 10 billion

  • Surface area of capillaries: 500-700 square meters (equivalent to a football field)

General Examination Overview
Inspection Phase

  • Assess for:

    • Size/Shape/Symmetry/Swelling

    • Skin Color/Rashes/Wounds

    • Color of Nail Beds

    • Presence of Hair

Palpation Phase

  • Check:

    • Skin texture and temperature

    • Distal pulses

    • Lymph nodes

    • Edema

Auscultation Phase

  • Bruits are typically best heard with the bell of the stethoscope.

Arterial Anatomy

  • Carotid artery: Medial to the sternal head of the sternocleidomastoid muscle.

  • Brachial artery: Medial to the biceps tendon.

  • Radial artery: On the radial side of the wrist.

  • Femoral artery: Inferior to the inguinal ligament in the inguinal crease.

  • Dorsalis Pedis: Lateral to the extensor hallucis longus.

  • Posterior tibial artery: Posterior to the medial malleolus.

Arterial Inspection Findings

  • Color Changes:

    • Paleness: Lack of arterial supply

    • Blue: Lack of oxygenation

    • Purple: Venous congestion

    • Brown/Rust colored: Hemoglobin pigmentation

    • Red: Inflammation or infection.

    • In darker-skinned individuals, check soles of the feet for changes.

Arterial Palpation Findings

  • Skin Temperature: Hot, cold, or warm

  • Skin Texture: Smooth or rough, thickened, or thinning

  • Pulses: Use grading scale:

    • 0: Absent

    • 1: Diminished

    • 2: Normal briskness

    • 3: Increased

    • 4: Bounding

  • Characteristics: Regularity of pulse, symmetry when comparing sides.

  • Thrills: A palpable vibratory sensation indicating turbulent flow consistent with obstruction.

Arterial Auscultation Techniques

  • Arteries to auscultate:

    • Carotid (have the patient hold their breath)

    • Aorta

    • Renal

    • Femoral

  • Bruit: Turbulent flow indicates partial obstruction, best heard low-pitched with a bell.

Special Tests for Arterial Assessment
Allen Test

  • Procedure:

    • Patient opens and closes fist quickly then holds tight.

    • Apply pressure over radial and ulnar arteries.

    • Ask the patient to open the hand slowly while releasing pressure on one artery. Observe for pink coloration return to assess collateral supply.

  • Note: Perform before arterial blood gas testing.

Adson's Test

  • Purpose: Determines compression of the subclavian artery in thoracic outlet syndrome.

  • Procedure:

    • Feel radial pulse, extend, abduct, rotate the arm.

    • Patient turns head toward side being tested; observe pulse for changes.

Roos Test

  • Procedure:

    • Arms abducted to 90°, externally rotated, elbows bent, induce tension.

    • Patient opens and closes hands slowly for 2-3 minutes. Positive test indicates weakness, numbness, or tingling.

Ankle-Brachial Index (ABI)

  • Purpose: Compares systolic pressure in the ankle verses brachial artery.

  • Normal resting ABI: 0.9 - 1.3 (suggests no significant narrowing).

  • Abnormal resting ABI:
    Less than 0.9 indicates Peripheral Arterial Disease (PAD).

    • 0.41 - 0.9: Mild to moderate PAD

    • 0.4 or below: Severe PAD

  • Formula: ( ext{ABI} = rac{ ext{ankle BP}}{ ext{arm BP}})

Postural Color Change Test

  • Assesses chronic peripheral arterial disease: Elevate affected legs for 1 minute, observe color change.

  • Normal should see return of pinkness within 10 seconds.

Venous Anatomy Overview
Upper Extremity Veins

  • Deep Veins Include:

    • Subclavian

    • Axillary

    • Brachial

    • Basilic

    • Median cubital

  • Superficial Veins Include:

    • Cephalic

    • Radial

    • Ulnar

Lower Extremity Veins

  • Deep Veins Include:

    • Common iliac

    • Internal iliac

    • External iliac

    • Femoral

    • Popliteal

  • Superficial Veins Include:

    • Great saphenous (medial leg)

    • Small saphenous (posterior calf)

Venous Examination Techniques
Inspection

  • Assess for:

    • Color changes (e.g., varicosities, ulcers, hemosiderin deposits, erythema)

    • Swelling patterns such as pitting edema

Palpation of Edema

  • Determining Type of Edema:

    • Pitting: Fluid overload or cardiac issue (indentation present).

    • Non-pitting: Lymphatic issue, skin appears hard and thickened (indentation absent).

Homan’s Sign

  • Procedure: Support thigh, bend leg slightly, and dorsiflex foot abruptly. Positive test indicates deep calf pain.

Lymphatic Anatomy

  • Primary Lymph Nodes and Their Drainage Regions:

    • Cervical nodes: Drain head and neck.

    • Axillary nodes: Drain remaining arm and breast.

    • Epitrochlear nodes: Drain the ulnar side of forearm and hand.

    • Inguinal nodes: Drain superficial abdomen, buttocks, external genitalia, vagina, and anus.

    • Popliteal nodes: Drain the region associated with the small saphenous vein.

Lymphatic System Function

  • The lymphatic system provides an accessory route for fluid movement from interstitial spaces into the blood, crucial for:

    • Removing proteins and large particles that enter tissue spaces, preventing their accumulation.

    • Facilitating nutrient absorption from the gastrointestinal tract, particularly fats.

Capillary Physiology

  • Hydrostatic vs. Oncotic Pressure:

    • Increased hydrostatic or decreased oncotic pressure in vessels leads to increased interstitial fluid causing edema.

    • Hydrostatic pressure forces fluids from blood into interstitial fluid, proteins in blood pull fluids back.

Lymphatic Examination Findings

  • Inspection Signs:

    • Red streaks (indicative of lymphangitis).

    • Enlarged nodes from infection or malignancy.

    • Edema due to obstruction.

  • Palpation Variants:

    • Tenderness over lymphangitis.

    • Palpable nodes classified by:

    • Size (greater than 1 cm = concerning)

    • Mobility (fixed nodes suggest malignancy).

Pathological Conditions: Peripheral Vascular Issues
Acute Arterial Occlusion

  • Caused by embolism (often thromboembolism).

  • Symptoms include:

    • Sudden severe extremity pain, often unilateral.

    • Coldness, weakness, and numbness.

    • Physical exam notes mottled, cool extremity with diminished or absent pulse.

Chronic Arterial Disease

  • Symptoms:

    • Intermittent claudication relieved by rest, muscle fatigue, numbness.

    • Physical findings may show decreased distal pulses, pallor upon elevation, and possible ulcers or gangrene.

    • ABI < 0.9 indicates PAD.

Deep Vein Thrombosis (DVT)

  • Characteristics:

    • Clot formation in larger veins, typically in the calf.

    • Symptoms may be painless but can create swelling.

    • Unilateral findings, not increased by movement.

    • Physical findings: swelling with pitting edema, discoloration, and possible Homan's sign.

  • Complications include Pulmonary Embolus.

Superficial Thrombophlebitis

  • Slower process than DVT with pain common.

  • Physical findings: redness and tenderness along the affected vein, minimal swelling.

Chronic Venous Insufficiency (CVI)

  • Characteristics of CVI:

    • Elevated venous pressure in the legs leads to valve damage and further complications.

  • Symptoms include:

    • Aching legs aggravated by standing, and alleviated by elevation.

  • Physical findings include pitting edema, rust-colored skin changes, thickened skin, and moist ulcers.

Lymphatic Pathologies
Lymphadenopathy

  • Benign Characteristics:

    • Size < 1 cm, tender, movable, discreet borders.

  • Malignant Characteristics:

    • Size > 1 cm, non-tender, rock-hard, fixed to surrounding tissues, difficult borders.

Lymphangitis

  • Result of localized bacterial infection, typically after skin injury. Symptoms include pain, fever, with visible red streaks and swollen, tender lymph nodes.

Lymphedema

  • Caused by obstruction or damage to lymph channels.

  • Symptoms include non-pitting edema, thickened skin, typically no change in pigmentation.

Clinical Application and Review Questions

  1. Which arteries can you auscultate?

  2. What is the purpose of the ankle-brachial index test?

  3. Identify concerning features of lymph nodes during examination.

  4. What conditions could indicate enlarged epitrochlear lymph nodes?

  5. Clinical findings to suspect if a patient is dyspneic, tachypneic, with chest pain and low PaO2 indicating pulmonary embolus.