History Taking & Physical ExaminationHistory Taking & Physical Examination

Ch12. Ch12.

CHAN SOVANDY, M.D.CHAN SOVANDY, M.D.

International University, Phnom Penh International University, Phnom Penh

OutlineOutline

• Anatomy and physiology Anatomy and physiology •Arteries, veins, lymphatic systemArteries, veins, lymphatic system

• Techniques of examination Techniques of examination •Arms, legsArms, legs

• lesions., edema, color, temperature, pulses lesions., edema, color, temperature, pulses

• Special techniques Special techniques •Evaluating the competency of venous values Evaluating the competency of venous values

•Evaluating pressure sores Evaluating pressure sores

•Evaluating the arterial supply to the hand Evaluating the arterial supply to the hand and feet.and feet.

Anatomy and Physiology – Anatomy and Physiology – Arteries Arteries • UEUE

•Brachial artery Brachial artery

•Radial and ulnar arteries are interconnected Radial and ulnar arteries are interconnected within the hand to protect against possible within the hand to protect against possible arterial occlusion.arterial occlusion.

• LELE•Femoral artery Femoral artery

•Popliteal artery Popliteal artery

•Posterior tibialis and dorsalis pedis are Posterior tibialis and dorsalis pedis are interconnected within the ankle to protect interconnected within the ankle to protect against possible arterial occlusion against possible arterial occlusion

Anatomy and Physiology – Anatomy and Physiology – ArteriesArteries • Arterial pulses Arterial pulses

• In the arm – 3 pulses In the arm – 3 pulses Brachial Brachial Radial Radial Ulnar Ulnar

• In the leg – 4 pulses In the leg – 4 pulses Female Female Popliteal Popliteal Posterior tibialis Posterior tibialis Dorsalis pedis Dorsalis pedis

Anatomy and Physiology – Anatomy and Physiology – veinsveins • The greats saphenous veins and the The greats saphenous veins and the

small saphenous veins are superficial small saphenous veins are superficial veins.veins.

• They anastomose with each other They anastomose with each other through many small superficial veins.through many small superficial veins.

• The communicating vein connects The communicating vein connects the deep femoral vein with the 2 the deep femoral vein with the 2 saphenous veins.saphenous veins.

Anatomy and Physiology – Anatomy and Physiology – Lymphatic system & Lymph Lymphatic system & Lymph nodesnodes • 85% of interstitial fluid at capillaries are 85% of interstitial fluid at capillaries are

reabsorbed at the venous ends, and the reabsorbed at the venous ends, and the remaining 15% are filtered at the remaining 15% are filtered at the lymphatic vessels and returned to the lymphatic vessels and returned to the circulation via subclavian veins.circulation via subclavian veins.

• The lymph transported in these The lymph transported in these channels is filtered through lymph channels is filtered through lymph nodes that are interposed along the nodes that are interposed along the way. Normal LNs are small except at way. Normal LNs are small except at inguinal areas where they can 2 cm in inguinal areas where they can 2 cm in diameter.diameter.

Anatomy and Physiology – Anatomy and Physiology – Changes with ageChanges with age

• Age lengthens the arteries, makes them Age lengthens the arteries, makes them tortuous, and typically stiffens their tortuous, and typically stiffens their walls (arteriosclerosis).walls (arteriosclerosis).

• Skin may get thin and dry with age, Skin may get thin and dry with age, nails may grow more slowly, hair on the nails may grow more slowly, hair on the legs often becomes scant.legs often becomes scant.

• Loss of arterial pulses from Loss of arterial pulses from atherosclerosis (and thrombosis) is not atherosclerosis (and thrombosis) is not a part of normal aging, and demands a part of normal aging, and demands careful evaluation.careful evaluation.

Techniques of examination – Techniques of examination – armsarms • InspectionInspection

• From the fingertips to the shoulders.From the fingertips to the shoulders.

• Note Note Size , symmetry, swelling Size , symmetry, swelling Venous pattern Venous pattern Color of the skin and nail beds Color of the skin and nail beds The texture of the skinThe texture of the skin

• Palpation Palpation • The radial (and ulnar) pulse The radial (and ulnar) pulse

• Compare the pulse in both arms Compare the pulse in both arms

• Tachycardia HR > 100, Bradycardia HR < 60Tachycardia HR > 100, Bradycardia HR < 60

• In Raynaud’s disease, wrist pulse are In Raynaud’s disease, wrist pulse are normal but spasm of distal arteries normal but spasm of distal arteries produces pallor.produces pallor.

Techniques of examination – Techniques of examination – armsarms • Feel for one or more epitroclear nodes.Feel for one or more epitroclear nodes.

• If the node is present, note its size, If the node is present, note its size, consistency, and tenderness.consistency, and tenderness.

• Epitrochlear nodes are difficult or Epitrochlear nodes are difficult or impossible to identify in most normal impossible to identify in most normal people.people.

• An enlarged epitrochlear node may be An enlarged epitrochlear node may be secondary to a lesion in its drainage or secondary to a lesion in its drainage or may be associated with generalized may be associated with generalized lymphadenopathy.lymphadenopathy.

Techniques of examination – Techniques of examination – legslegs • Inspection Inspection

• From groin and buttocks to feetFrom groin and buttocks to feet

• Note Note Size, symmetry, swelling Size, symmetry, swelling Venous pattern and any venous enlargement Venous pattern and any venous enlargement Color of the skin including pigmentation, hair Color of the skin including pigmentation, hair

distribution and nail beds. Hyper pigmentation and distribution and nail beds. Hyper pigmentation and hair loss suggest arterial insufficiency.hair loss suggest arterial insufficiency.

The texture of the skin The texture of the skin

• Palpation Palpation • Inguinal nodesInguinal nodes

Note their size, consistency, tenderness Note their size, consistency, tenderness

• Pulses Pulses A diminished or absent pulse indicates partial or A diminished or absent pulse indicates partial or

complete arterial occlusion proximally. Occlusion complete arterial occlusion proximally. Occlusion could be from atheroma of atherosclerosis, could be from atheroma of atherosclerosis, thrombosis, or embolus.thrombosis, or embolus.

Techniques of examination - Techniques of examination - legslegs• Palpation (cont’d)Palpation (cont’d)

•The temperature The temperature Bilateral coldness is most often due to a cold Bilateral coldness is most often due to a cold

environment, anxiety, or arterial insufficiency environment, anxiety, or arterial insufficiency (unilateral).(unilateral).

•The edema The edema A difference of over 1 cm just above the ankle A difference of over 1 cm just above the ankle

or 2 cm at the calfor 2 cm at the calf Pitting edema: press firmly but gently with Pitting edema: press firmly but gently with

your thumb for at least 5 seconds your thumb for at least 5 seconds Note the extent of the swelling. How far up Note the extent of the swelling. How far up

the leg does it go?the leg does it go? Is the welling unilateral or bilateral? Is the welling unilateral or bilateral? Are the veins unusually prominent ?Are the veins unusually prominent ?

Techniques of examination - Techniques of examination - legslegs• In the presence of LE edema, look for In the presence of LE edema, look for

possible cause of peripheral vascular possible cause of peripheral vascular system system

•Recent DVT Recent DVT

•Chronic venous insufficiency due to: Chronic venous insufficiency due to: Previous DVTPrevious DVT Incompetence of the venous valves Incompetence of the venous valves

• Lymphedema from proximal Lymphedema from proximal obstructionobstruction

Techniques of examination – Techniques of examination – LegsLegs • DVTDVT

• Usually of the LE. Pt presents with LE pain and swollen Usually of the LE. Pt presents with LE pain and swollen

• Tender on venous palpationTender on venous palpation Femoral vein: medial to the femoral pulse Femoral vein: medial to the femoral pulse Calf tenderness on palpation and on stretching. A Calf tenderness on palpation and on stretching. A

tender cord may be palpable.tender cord may be palpable.

• Note the color of the skin:Note the color of the skin: Is there a local area of redness (thrombophlebitis?)Is there a local area of redness (thrombophlebitis?) Temperature Temperature Are the brownish area near the ankles? Are the brownish area near the ankles? A brownish color or ulcers just above the ankle suggest A brownish color or ulcers just above the ankle suggest

chronic venous insufficiency. chronic venous insufficiency.

• Feel the thickness of the skin.Feel the thickness of the skin. It occurs in lymphedema and advanced venous It occurs in lymphedema and advanced venous

insufficiency.insufficiency.

Techniques of examination - Techniques of examination - legslegs• Inspect the saphenous for varicosities Inspect the saphenous for varicosities

•Ask the patient to stand, allows any varicosities Ask the patient to stand, allows any varicosities to fill with blood and make them visible. to fill with blood and make them visible.

•You can miss them when the patient is in a You can miss them when the patient is in a supine position. supine position.

• Feel for any varicositiesFeel for any varicosities

• Noting any signs of thrombohlebitis Noting any signs of thrombohlebitis

• Varicose veins are dilated and Varicose veins are dilated and tortuous . Their walls may fell tortuous . Their walls may fell somewhat thickened.somewhat thickened.

Evaluating the competency of Evaluating the competency of venous valuesvenous values

Evaluating the competency of Evaluating the competency of venous valvesvenous valves

• Trendelenburg test (the retrograde filling)Trendelenburg test (the retrograde filling)• Helps to assess valvular competency in the Helps to assess valvular competency in the

communicating veins communicating veins • Elevate the patient’s leg t o 90Elevate the patient’s leg t o 900 0 to empty in of to empty in of

venous blood.venous blood.• Next, occlude the great saphenuos vein in the upper Next, occlude the great saphenuos vein in the upper

thigh by a tourniquet wrapped tightly enough to thigh by a tourniquet wrapped tightly enough to occlude this vein but not the deeper vessels.occlude this vein but not the deeper vessels.

• Then ask the patient to stand while keeping the vein Then ask the patient to stand while keeping the vein occluded and watch for venous filling in the leg.occluded and watch for venous filling in the leg.

• Normally the saphenous veins fills from below, Normally the saphenous veins fills from below, talking about 35 seconds as blood flows through the talking about 35 seconds as blood flows through the capillary bed into the venous system.capillary bed into the venous system.

Rapid filling of the superficial veins (less than 35 Rapid filling of the superficial veins (less than 35 seconds) indicates the incompetent valves in the seconds) indicates the incompetent valves in the communicating veins. Blood flow quickly in a communicating veins. Blood flow quickly in a retrograde direction from the saphenous system.retrograde direction from the saphenous system.

Evaluating pressure soresEvaluating pressure sores

• Inspect for pressure sores (bedsores)Inspect for pressure sores (bedsores)•Occur in bedridden pt Occur in bedridden pt

•From poor blood flow to the skin due to From poor blood flow to the skin due to compression compression

•Seen on the skin overlying the sacrum, Seen on the skin overlying the sacrum, buttocks, greater trochanters, knees, and buttocks, greater trochanters, knees, and heels.heels.

•Roll the patient onto one side to get a good Roll the patient onto one side to get a good view of the sacrum and buttocks.view of the sacrum and buttocks.

Evaluating arterial supplyEvaluating arterial supply

• The Allen testThe Allen test•Test to assure the patency of the ulnar Test to assure the patency of the ulnar

artery be before punching the radial artery artery be before punching the radial artery for blood samples for blood samples

•Patient to make a tight fist, you compress Patient to make a tight fist, you compress both radial and ulnar arteries firmly.both radial and ulnar arteries firmly.

•Then ask the patient to open the hand into a Then ask the patient to open the hand into a relaxed, slightly flexed position. relaxed, slightly flexed position.

•Release your pressure over the ulnar artery. Release your pressure over the ulnar artery. If the ulnar artery is patient, the palm If the ulnar artery is patient, the palm flushes within about 3 to 5 seconds.flushes within about 3 to 5 seconds.

•Potency of the radial artery may be tested Potency of the radial artery may be tested by the same method.by the same method.

SummarySummary

• Upper and lower limbs vessels Upper and lower limbs vessels

• Arteries – pulses, color, temperature Arteries – pulses, color, temperature

• Veins – varicosis, color, edema Veins – varicosis, color, edema

• Lymphatic system – edema Lymphatic system – edema

• Special techniques Special techniques