Peripheral Vascular & Lymphatic System Health History

The Peripheral Vascular & Lymphatic System

• Focuses on common or concerning symptoms and health history for health assessment.

Health History Questions

• Used to identify symptoms of peripheral arterial and venous diseases.
• Recommended, especially in patients older than 50 years and those with risk factors, such as smoking, diabetes, hypertension, elevated cholesterol, or coronary artery disease.

Common or Concerning Symptoms

• Pain in the arms or legs.
• Intermittent Claudication.
• Cold, numbness, or pallor in the legs along with hair loss.
• Swelling in the calves, legs, or feet.
• Swelling with redness or tenderness.

Key Questions

• Is there pain or cramping in legs during walking or exertion? (intermittent claudication)
• Is the pain relieved by rest within 10 minutes?
• What is the location of the pain?
• What distance can the patient walk before symptoms occur?
• Inquire about coldness, numbness, or pallor in the legs or feet and whether hair is present on shins.
• Ask about aching or pain at rest in the lower leg or foot; if pain is alleviated by elevating the legs.
• Ask about fatigue or aching in the lower legs with prolonged standing.
• Determine if swelling of the feet or legs is present; including its location, time of day it is present and whether it is bilateral or unilateral.
• Determine if varicose veins are present, their location, duration, and any discomfort from them.
• Check also for wounds of the legs or feet that heal slowly, their location, duration and cause.
• Ask if fingertips or toes change color in cold weather and about erectile dysfunction or abdominal pain after eating.
• Investigate any tender or swollen lymph nodes (glands).

Past History

• Check for medications that especially oral contraceptives or hormone replacement therapy.
• Pregnancy or recent childbirth.
• Inflammatory diseases like lupus, rheumatoid arthritis, and irritable bowel disease.
• Active cancer and coronary artery disease (CAD) and heart attack, congestive heart failure.
• Stroke (cerebral arterial disease)
• Clotting disorders and hypertension and diabetes.
• Check for problems in circulation, such as blood clots, leg ulcers, swelling, or poor healing of wounds.

Family History

• Peripheral vascular disease.
• Varicose veins.
• Abdominal aortic aneurysm, CAD (Coronary Artery Disease).
• Sudden death younger than 60 years of age.
• Diabetes.

Lifestyle or Health Patterns

• Jobs requiring prolonged standing or sitting.
• Sedentary lifestyle.
• Decreased mobility such as paralysis or cast.

Physical Examination Considerations

• Major surgery or fracture of a long bone in the last 4 weeks.
• Review risk factors, including obesity and smoking.
• Hyperlipidemia.
• Note constrictive clothing or central venous lines.

Equipment Needed

• Tape measure and Doppler ultrasound device and Tourniquet or blood pressure cuff.

Important Areas of Examination

• Arms: Check size, symmetry, skin color, radial pulse, brachial pulse, and epitrochlear lymph nodes.
• Legs: Check size, symmetry, skin color, tenderness, femoral pulse, inguinal lymph nodes, popliteal, dorsalis pedis, posterior tibial pulses, and peripheral edema.
• Urged close examination of the peripheral vascular system because PAD is often asymptomatic and underdiagnosed, leading to significant morbidity and mortality.

Arms Inspection

• Inspect both arms from the fingertips to the shoulders:
  • Note their size, symmetry, swelling, and any lesions.
  • Observe the venous pattern.
  • Note the color of the skin and nail beds and the texture of the skin.
• Lymphedema of the arm and hand may follow axillary node dissection and radiation therapy.
• Prominent veins in an edematous arm can suggest venous obstruction.
• Ensure to palpate the temperature of the arms and hands simultaneously with the backs of your fingers.
• Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally.
• In Raynaud disease, wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers.

Painful Peripheral Vascular Disorders and Their Mimics

• Arterial Disorders: Atherosclerosis obliterans causes episodic muscular ischemia induced by exercise due to atherosclerosis of large or medium-sized arteries, resulting in intermittent claudication.
• Acute Arterial Occlusion: Embolism or thrombosis, possibly superimposed on arteriosclerosis obliterans, causes distal pain, usually involving the foot and leg.
• Raynaud Disease and Phenomenon: Episodic spasm of the small arteries and arterioles with no vascular occlusion causes distal portions of one or more fingers, causing pain unless fingertip ulcers develop. Numbness and tingling are common.
• Venous Disorders: Superficial Thrombophlebitis causes clot formation and acute inflammation in a superficial vein.
• Deep Venous Thrombosis (DVT) causes clot formation in a deep vein resulting in tight, bursting pain, if present, usually in the calf.
• Chronic Venous Insufficiency (deep) causes chronic venous engorgement secondary to venous occlusion or incompetency of venous valves resulting in diffuse aching of the leg.

Grading Amplitude of Arterial Pulses

• One system uses a scale of 0 to 3.
  • 3+ Bounding.
  • 2+ Brisk, expected (normal).
  • 1+ Diminished, weaker than expected.
  • 0 Absent, unable to palpate.
• The other system a scale of 0 to 4.
  • 0. Absent
  • 1+ Palpable, but thready and weak; easily obliterated.
  • 2+ Normal, easily identified; not easily obliterated.
  • 3+ Increased pulse; moderate pressure for obliteration.
  • 4+ Full, bounding; cannot obliterate.

Assessing Brachial Pulse

• Flex the patient's elbow slightly, and palpate the artery just medial to the biceps tendon at the antecubital crease.
• The brachial artery can be felt higher in the arm in the groove between the biceps and triceps muscles.

Epitrochlear Nodes

• Feel for the epitrochlear nodes with the patient's elbow flexed to about 90° and the forearm supported by your hand.
• Reach around behind the arm and feel in the groove between the biceps and triceps muscles, about 3 cm above the medial epicondyle and note its size, consistency, and tenderness if a node is present.
• An enlarged epitrochlear node may arise from local or distal infection or may be associated with generalized lymphadenopathy.

Legs Inspection

• Inspect both legs from the groin and buttocks to the feet
  • Note their size, symmetry, and edema.
  • Measure leg circumferences in centimeters if discrepancy is suspected.
  • Note the venous pattern and any venous enlargement or varicosities.
• Check for pigmentation, rashes, scars, or ulcers and the color and texture of the skin and the color of the nail beds.
• Check the distribution of hair on the lower legs, feet, and toes and also for brownish areas (or increased pigmentation on dark-skinned clients) near the ankles.
• The brown discoloration is caused by hemosiderin released from the red blood cells that seep into the skin with edema and break down.
• Note the location, size, and depth of any ulcers in the skin.
• Check if the edges of the wound are well demarcated and if there is bleeding.

Chronic Arterial Insufficiency

• Pain: Intermittent claudication, progressing to pain at rest.
• Mechanism: Tissue ischemia.
• Pulses: Decreased or absent.
• Color: Pale, especially on elevation; dusky red on dependency.
• Temperature: Cool.
• Edema: Absent or mild; may develop as the patient tries to relieve rest pain by lowering the leg.
• Skin Changes: Thin, shiny, atrophic skin, loss of hair over the foot and toes, nails thickened and ridged.
• Ulceration: If present, involves toes or points of trauma on feet.
• Gangrene: May develop.

Chronic Venous Insufficiency

• Pain: Ulcer often painful; generalized leg aching, especially at the end of day.
• Mechanism: Venous hypertension.
• Pulses: Normal, though may be difficult to feel through edema
• Color: Normal, or cyanotic on dependency Petechiae and then brown pigmentation appear with chronicity.
• Temperature: Normal.
• Edema: Present, often marked.
• Skin Changes: Brown pigmentation around the ankle, stasis dermatitis, and possible thickening of the skin and narrowing of the leg as scarring develops.
• Ulceration: If present, develops at sides of the ankle, especially medially.
• Gangrene: Does not develop.

Common Ulcers of the Ankles and Feet

• Chronic Venous Insufficiency Ulcer: Appears over the medial and sometimes the lateral malleolus with small, painful granulation tissue and fibrin.
• Arterial Insufficiency Ulcer: occurs in the toes, feet, or areas of trauma, showing no callus or excess pigment around the surroundings of the skin.
• Neuropathic Ulcer: Condition develops in pressure points of areas with diminished sensation; seen in diabetic neuropathy, neurologic disorders, surrounding skin is calloused.

Palpation of Legs and Feet

• Palpate the temperature of both legs and feet simultaneously with the backs of your hands ensuring to compare temperature.
• Bilateral coolness is most often caused by a cold environment or anxiety.
• Coldness, especially when unilateral or associated with other signs, suggests arterial insufficiency from inadequate arterial circulation.
• Palpate for edema; comparing one foot and leg with the other, noting their relative size and the prominence of veins, tendons, and bones.

Pitting Edema

• Press firmly but gently with your thumb for at least 5 seconds over the dorsum of each foot, behind each medial malleolus, and over the shins.
• Look for pitting - a depression caused by pressure from your thumb.
• Normally there is none.
• The severity of edema is graded on a four-point scale.

Femoral Pulse

• Press deeply, below the inguinal ligament and about midway between the anterior superior iliac spine and the symphysis pubis.
• The use of two hands, one on top of the other, may facilitate this examination, especially in obese patients.
• An exaggerated, widened femoral pulse suggests a femoral aneurysm, a pathologic dilatation of the artery.

Popliteal Pulse

• Keep knee flexed with the leg relaxed.
• Place the fingertips of both hands so that they meet in the midline behind the knee and press deeply into the popliteal fossa.
• The popliteal pulse is often more difficult to find than other pulses and is deeper and feels more diffuse if you cannot feel the popliteal pulse with this approach.
• Have the patient lie prone and flex the patient's knee to about 90°, let the lower leg relax a press with two thumbs deeply into the popliteal fossa.

Special Considerations

• Atherosclerosis most commonly obstructs arterial circulation in the thigh, thus the femoral pulse is normal, while the popliteal pulse can be decreased or absent.
• The dorsalis pedis artery may be congenitally absent or may branch higher in the ankle, search for a pulse more laterally.
• Decreased or absent pedal pulses (assuming a warm environment) with normal femoral and popliteal pulses suggest occlusive disease in the lower popliteal artery or its branches.

Posterior Tibial Pulse

• Curve fingers behind, slightly below the medial malleolus of the ankle.
• May be hard to feel in a fat or edematous ankle.
• Sudden arterial occlusion from embolism or thrombosis causes pain and numbness or tingling.
• The limb distal to the occlusion becomes cold, pale, and pulseless, which requires emergency treatment.
• If collateral circulation is good, only numbness and coolness may result.

Superficial Inguinal Nodes

• Palpate the superficial inguinal nodes, including both the horizontal and the vertical groups, noting their size, consistency, and discreteness.
• Indicate any tenderness, and if nontender, discrete inguinal nodes up to 1 cm or even 2 cm in diameter are frequently palpable in normal people.

Evaluating Arterial Supply to the Hand

• Assess for arterial insufficiency by trying to feel the ulnar pulse as well as the radial and brachial pulses.
• Feel deeply on the flexor surface of the wrist medially, partially flexing the patient's wrist which may help you feel the pulse the arterial supply to the hand.
• Arterial occlusive disease is much less common in the arms, and absent or diminished pulses at the wrist are found in acute embolic occlusion and in Buerger disease, or thromboangiitis obliterans.

Allen Test

• Used to compare patency of the ulnar and radial arteries it also ensures the patency of the ulnar artery before puncturing for blood samples or arterial lines.
• The patient should rest with the hands in lap, palms up and ask the patient to make a tight fist with one hand; then compress both radial and ulnar arteries firmly between your thumbs and fingers.
• Extending the hand fully may cause pallor and a falsely positive test.
• Release your pressure over the ulnar artery showing that if the ulnar artery is patent, the palm flushes within 3 to 5 seconds.

Arterial Supply to the Legs

• If pain or diminished pulses suggest arterial insufficiency, look for postural color changes and to check for the arterial supply to the legs.
• Patient lying down, raise both legs to about 60° until maximal pallor of the feet develops usually within 1 minute, and ask to patient flex the ankles up and down to drain venous blood.
• If skin is light evaluate, in light-skinned persons, either maintenance of normal color, as seen in the right foot, or slight pallor is normal.
• In dark-skinned persons, evaluate the soles of the feet or nail beds for pallor.
• Marked pallor on elevation suggests arterial insufficiency.

Persisting Rubor

• Persisting rubor on dependency suggests arterial insufficiency.
• When veins are incompetent, dependent rubor, and the timing of color return and venous filling.
• In these cases this is not a reliable tests of arterial insufficiency.

Ankle-Brachial Index (ABI)

• Should be performed if a patient has risk factors for peripheral artery disease and a noninvasive way to assess blood flow in the ankle to arm by measuring systolic blood pressure.
  • Doppler device with 8-MHz probe.
  • Doppler gel.
  • Blood pressure cuffs for arm and leg 40% limb circumference. Procedure:
• Patient should avoid caffeine and tobacco for at least 1 hour before the procedure.
• Explain and position patient in supine position.
  • Client should rest supine for 10-20 minutes before the procedure.
  • Apply BP cuff to patient's arm + feel for brachial pulse.
  • Apply a small mound of gel over the pulse/ turn on the Doppler.
• Place tip of the Doppler probe in the gel at a 45o angle and listen for whooshing sound
  • (Indicates the pulse: may be adjusted between 30-60o to maximize sound.)
• Inflate BP cuff until the sound isn't heard, then inflate 20-30mm Hg above that point.
  • Deflate cuff at a rate of 2-4mm Hg/second until the sound returns.
  • (This is Systolic BP)
  • Repeat in other arm. -Place the ankle BP cuff just above malleoli. -Locate the posterior tibial pulse w Doppler and inflate the cuff 20- 30mm Hg above the the number the pulse is last heard.
  • Slowly release the pressure until pulse is heard
  • This is systolic pressure, repeat Dorsalis Pedis.

Venous Test

• Retrograde Filling (Trendelenburg)
• Assesses valvular competency in commucating and saphenosus veins with these step: - Pt supine, elevate on leg to 90o to empty venous blood - Occlude the great saphenous vein un upper thigh by manual compression - Use enough pressure to occlude vein, but not deeper vessels. - Pt stand ( while keep vein occluded), watch venous filling in leg. - Normally, saphenous vein filling about 35 seconds. Normal : The saphenous vein fills from below, taking about 35 seconds as blood flows through the capillary bed into the venous system.
• After pt stands (20 seconds)

Pulsus Alternans

• Rhythm of pulse remains regular, but the arterial pulse force alternate Indication: Severe left-sided heart failure Test: Apply light pressure on radial or femoral artery to confirm findings with a blood pressure cuff:

• Korotoff sounds Alternately loud and soft Korotoff with doubling of the apparent heart rate at the cuff declines.

• It can be easier to notice the Alternately when the patient is an upright position

Paradoxical Pulse Test

• Inflation the BP cuff around the patient's usual systolic pressure

• Patient Breathing is important: Lower Cuff pressure (slow) till the pressure that sounds start coming Note the where sounds are first heard

• Drop the pressure until sounds throughout entire respiratory cycle are heared

• Where hear hear completely the same way (inspiration + expiration)

Health Promotion

• Health promotion and counseling regarding arterial disease:
  • Smoking cessation.
  • Weight control
  • Exercise program.
  • Hypertension control
  • Hyperlipidemia control
  • Diabetes management
  • Limiting alcohol intake
  • Foot care.
• Health promotion and couseling regarding venous disease:
  • Avoid Prolonged sitting and standing.
  • Avoid Constrictive clothing ( Girdles)