The physical examination of the venous and arterial structures of the vascular system is a critical component of patients’ evaluation. You can gain great insight into their overall cardiovascular status, specifically the detection of peripheral artery disease (PAD) of the lower extremities, which is associated with an increased risk of stroke and cardiovascular events.
- 1.
Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally for:
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Rate
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Rhythm
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Contour
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Amplitude
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- 2.
Auscultate the carotid, abdominal aorta, and the renal, iliac, and femoral arteries for bruits.
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With the patient reclining at a 45-degree angle, inspect for jugular venous pulsations and distention; differentiate jugular and carotid pulse waves, and measure jugular venous pressure.
- 4.
Inspect the extremities for sufficiency of arteries and veins for:
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Color, skin texture, and nail changes
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Presence of hair
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Muscular atrophy
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Edema or swelling
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Varicose veins
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- 5.
Palpate the extremities for:
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Warmth
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Pulse quality
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Tenderness along any superficial vein
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Pitting edema
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Anatomy and Physiology
The great vessels, the arteries leading from and the veins leading to the heart, are located in close proximity at the base of the heart. They include the aorta, superior and inferior venae cavae, pulmonary arteries, and pulmonary veins ( Fig. 16.1 ). The aorta carries oxygenated blood out of the left ventricle to the body. The pulmonary artery, which leaves the right ventricle and divides almost immediately into right and left branches, carries deoxygenated blood to the lungs. The superior and inferior venae cavae carry deoxygenated blood from the upper and lower body, respectively, to the right atrium. The pulmonary veins return oxygenated blood from the lungs to the left atrium.
Blood Circulation
Once it leaves the heart, blood flows through two circulatory systems, the pulmonary and the systemic ( Fig. 16.2 ). The pulmonary circulation routes blood through the lungs, where it is oxygenated before returning to the left atrium and ventricle of the heart. Venous blood arrives at the right atrium via the superior and inferior vena cavae and moves through the tricuspid valve to the right ventricle. During systole, deoxygenated blood is ejected through the pulmonic valve into the pulmonary artery; it travels through the pulmonary arteries, arterioles, and capillaries until it reaches the alveoli, where gas exchange occurs.
Oxygenated blood of the systemic circulation returns to the heart and enters the systemic circulation through the pulmonary veins into the left atrium and then through the mitral valve into the left ventricle. The left ventricle contracts, forcing a volume of blood with each beat (stroke volume) through the aortic valve into the aorta where it is distributed systemically through the arteries and capillaries. In the capillary bed, oxygen is provided to the tissues of the body; the now-deoxygenated blood is carbon dioxide–rich. It passes into the venous system and returns to the heart via the superior and inferior vena cavae and into the right atrium ( Fig. 16.3 ).
The structure of the arteries and veins reflects their function. The arteries are thicker with a greater smooth muscle layer and less ability to stretch and expand (distension) from internal pressure. They are subjected to much more pressure than the veins. The veins are more distensible than the arteries ( Fig. 16.4 ). Venous return occurs at a lower pressure than blood flow through the arteries, and veins contain valves to keep blood flowing in one direction. If circulatory volume increases significantly, the veins can expand and act as a repository for the extra volume.
Arterial Pulse and Pressure
The palpable and sometimes visible arterial pulses are the result of ventricular systole, which produces a pressure wave throughout the arterial system (arterial pulse). It takes barely 0.2 second for the impact of this wave to be felt in the dorsalis pedis artery within the foot. The arterial blood pressure is the force exerted against the wall of an artery as the bolus of blood exits the heart’s left ventricle with contraction.
The pulse usually is felt as a forceful wave that is smooth and more rapid on the ascending part of the wave; it becomes domed, less steep, and slower on the descending part ( Fig. 16.5 ). Because the carotid arteries are the most accessible of the arteries closest to the heart, they have the most definitive pulse for evaluation of cardiac function.
The following variables contribute to the characteristics of the pulses:
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Volume of blood ejected (stroke volume)
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Distensibility of the aorta and large arteries
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Obstruction of blood flow (e.g., narrowing of aortic valve [stenosis] or aorta [coarctation], vasculitis—blood vessel inflammation with narrowing—or PAD)
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Peripheral artery resistance
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Viscosity of the blood
Jugular Venous Pulse and Pressure
The jugular veins, which empty directly into the superior vena cava, reflect the activity of the right side of the heart and offer clues to its competency. The level at which the jugular venous pulse is visible gives an indication of right atrial pressure.
The external jugular veins are more superficial and more visible bilaterally above the clavicle, close to the insertion of the sternocleidomastoid muscles. The larger internal jugular veins run deep to the sternocleidomastoids, near the carotid arteries, and are less accessible to inspection ( Fig. 16.6 ).
The activity of the right side of the heart is transmitted back through the jugular veins as a pulse 1
1 Although often referred to as a pulse, this is not the same as an arterial pulse because it is reflected back from the right heart rather than pushed forward by the left heart. Unlike arterial pulses, it cannot be palpated, only visualized.
that has five identifiable components—three peaks and two descending slopes ( Fig. 16.7 ):| a wave | The upward a wave, the first and most prominent component, is the result of a brief backflow of blood to the vena cava during right atrial contraction. This peaks slightly before the first heart sound (S1). |
| c wave | The upward c wave is a transmitted impulse from the vigorous backward push produced by closure of the tricuspid valve during right ventricular systole. |
| v wave | The upward v wave is caused by the increasing volume and concomitant increasing pressure in the right atrium. It occurs after the c wave, late in ventricular systole. |
| x slope | The downward x slope is caused by passive atrial filling. This ends with the initiation of the v wave. |
| y slope | The y slope following the v wave reflects the open tricuspid valve and the rapid filling of the right ventricle. |
Infants and Children
At birth the cutting of the umbilical cord, through which oxygen has been provided in utero, requires the infant to begin breathing. The onset of respiration expands the lungs and carries air to the alveoli. Pulmonary vascular resistance drops, allowing blood to flow more freely to the lungs. Systemic vascular resistance increases. The ductus arteriosus closes, usually within the first 12 to 14 hours of life. Once pulmonary vascular resistance is lower than systemic resistance, blood flows into the pulmonary arteries rather than across the interatrial foramen ovale. The interatrial foramen ovale is functionally closed by the shifting pressures between the right and left sides of the heart.
Pregnant Patients
During pregnancy, the systemic vascular resistance decreases and peripheral vasodilation occurs, often resulting in palmar erythema and spider telangiectasias. The systolic blood pressure decreases slightly. There is a greater decrease in the diastolic pressure. The lowest levels occur in the second trimester and then rise but still remain below blood pressure readings before pregnancy. Maternal position affects blood pressure. Lower blood pressure can be noted when the patient is supine during the third trimester. This lower pressure is secondary to venous compression of the vena cava and impaired venous return. Blood in the lower extremities tends to pool in later pregnancy—except when the patient is in the lateral recumbent position—as a result of compression of the pelvic veins and inferior vena cava by the enlarged uterus. The compression may result in an increase in dependent edema, varicosities of the legs and vulva, and hemorrhoids.
Older Adults
Calcification and plaque buildup in the walls of the arteries can cause stiffness as well as dilation of the aorta, aortic branches, and carotid arteries. The arterial walls lose elasticity and vasomotor tone and are less distensible. The resulting increased peripheral vascular resistance may lead to elevated blood pressure, especially systolic.
Review of Related History
For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing on the physical examination and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary or alternative therapies are relevant for each.
History of Present Illness
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Leg pain or cramps
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Onset and duration: with activity or rest, recent injury or immobilization
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Character
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Continuous burning in toes, pain in thighs or buttocks, pain over specific location, induced by activity
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Skin changes: cold skin, pallor, sores, redness or warmth over vein, visible veins, darkened or ischemic skin
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Swelling of the leg
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Limping: pain in buttock or calf with walking (claudication)
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Waking at night with leg pain
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Swollen ankles
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Onset and duration: present in the morning, appearing as the day progresses, sudden onset, insidious onset
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Related circumstances: recent and long travel, postoperative immobilization, recent travel to high elevations
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Associated symptoms: onset of nocturia, increased frequency of urination, increasing shortness of breath
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Treatment attempted (including rest, massage, heat, elevation)
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Medications: heparin, warfarin, diuretics, antihypertensive medications
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Past Medical History
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Cardiac surgery or hospitalization for cardiac evaluation or disorder, congenital heart defect, surgical or interventional vascular catheterization procedures
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Chronic illness: hypertension and studies to define its cause, bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction, stroke, vasculitis, thrombosis, transient ischemic attacks, coronary artery disease, atrial fibrillation or other type of dysrhythmia
Family History
Family members with risk factors, morbidity, and mortality related to cardiovascular system; hypertension, dyslipidemia, diabetes, heart disease, thrombosis, peripheral vascular disease, abdominal aortic aneurysms, ages at time of illness or death
Personal and Social History
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Employment: physical demands; environmental hazards such as heat, chemicals, dust; sources of emotional stress
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Tobacco: type (cigarettes, cigars, pipe, chewing tobacco, snuff); duration of use; amount; efforts to quit and methods used; age started and, perhaps, stopped; pack-years (Number of years smoking × Number of packs per day)
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Nutritional status
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Usual diet: proportion of fat, food preferences, history of dieting
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Weight: loss or gain, amount and rate
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Exercise: type, amount, frequency, intensity
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Use of alcohol: amount consumed, frequency, duration of current intake
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Use of recreational drugs: intravenous drug use, cocaine
Infants and Children
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Hemophilia
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Sickle cell disease
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Renal disease
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Coarctation of the aorta
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Leg cramps during exercise
Pregnant Patients
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Blood pressure: prepregnancy levels, elevation during pregnancy; evidence of preeclampsia with associated symptoms and signs such as headaches, visual changes, nausea and vomiting, epigastric pain, right upper quadrant pain, oliguria, rapid onset of edema (facial, abdominal, or peripheral), hyperreflexia, proteinuria, unusual bruising or bleeding. See Risk Factors: “Preeclampsia .”
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Legs: edema, varicosities, pain or discomfort. See Risk Factors: “Varicose Veins .”
Age older than 40 years of age
First pregnancy
Preexisting chronic hypertension
Renal disease or diabetes mellitus
Multifetal gestation
Family history of preeclampsia or gestational hypertension
Previous preeclampsia or gestational hypertension
Obesity
Older Adults
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Leg edema: pattern, frequency, time of day most pronounced
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Interference with activities of daily living
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Ability of the patient and family to cope with the condition
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Claudication: area involved, unilateral or bilateral, distance one can walk before its onset, sensation, length of time required for relief
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Medications used for relief; efficacy of drugs
Gender: four times more common in women than men (during pregnancy in particular, increased hormonal levels weaken the walls of the vein and result in failure of the valves)
Genetic predisposition (children of women with varicosities)
Tobacco use, sedentary lifestyle (habitual inactivity allows blood to pool in the veins, resulting in edema), increased body mass index
Age: the veins of older adults are less elastic and more likely to be varicose
History of lower extremity trauma or venous thrombosis
Examination and Findings
Equipment
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Marking pencil
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Two separate centimeter rulers at least 15 cm long
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Stethoscope with bell and diaphragm
Palpation
The pulses are best palpated over arteries that are close to the surface of the body and lie over bones. These include the carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries ( Fig. 16.8 ).
An arterial pulsation is essentially a bounding wave of blood that diminishes with increasing distance from the heart. The carotid pulses are most easily accessible and closest to the cardiac source, making them most useful in evaluating heart function. Examine the arterial pulses in the extremities to determine the sufficiency of the entire arterial circulation. Palpate at least one pulse point in each extremity, usually at the most distal point (see Clinical Pearl, “Carotid Palpation ”).
When palpating the carotid arteries, never palpate both sides simultaneously. Excessive carotid sinus massage can cause slowing of the pulse and a drop in blood pressure and compromise blood flow to the brain, leading to syncope. If you have difficulty feeling the pulse, rotate the patient’s head to the side being examined to relax the sternocleidomastoid muscle.
When examining the arterial pulses, the thumb may be used, especially if vessels have a tendency to move when probed by fingers. In this setting the thumb is particularly useful in “fixing” the brachial and even the femoral pulses. Palpate firmly but not so hard as to occlude the artery. The exception to this is when doing the Allen test to ensure ulnar artery patency before radial artery puncture ( Box 16.1 ).
This test assesses the patency of the ulnar artery. Perform this test before radial artery puncture for arterial blood gas sampling or the insertion of a radial arterial catheter.
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With the patient’s palm facing upward, compress the radial and ulnar artery with your fingers (A).
- 2.
Have the patient close and open the fist five times and then leave the blanched palm open.
- 3.
Release pressure on the ulnar artery alone and watch for palmar reperfusion within 4 to 5 seconds.
- 4.
If palmar reperfusion does not occur, suspect ulnar artery insufficiency and do not puncture the radial artery (B).
