Editing Vascular clinical evaluation

== History ==

* Broad categories of complaints:
** Pain
** Weakness
** Neurosensory complaints
*** Warmth
*** Coolness
*** Numbness
*** Hypersensitivity
** Discolouration
** Swelling
** Tissue loss/ulceration
** Varicosities
* Ask about:
** Duration of symptoms
** Progression or changes since initial onset
** Location
** Character or quality
** Extent of functional limitation
** Precipitating/aggravating
** Associated signs and symptoms
** Risk factors

== Examination ==

* Inspection
** Skin changes - atrophy, cyanosis, pallor, rubor, hair distribution, nail thickening
** Oedema
** Tissue loss and ulceration - location, size, depth, cellulitis
** Ulcers
*** [[File:DDx_common_leg_ulcers_-_from_Rutherford's.png|frameless|675x675px]]
*** Apparently, more than 95% of all leg/foot ulcers will fit neatly into a category - arterial, venous, neuropathic
*** Others:
**** Vasculitis - multiple punched out ulcers with inflamed, indurated base, with a biopsy suggesting fat necrosis or chronic panniculitis
**** Hypertensive ulcers - focal infarcts - very painful - located around the malleoli
**** Underlying osteomyelitis
**** Malignant skin lesion
** Motor function
* Palpation
** Changes in temperature/sensation - compare with other size
** Pulses - absent, decreased, normal, prominent (aneurysm)
*** Superficial temporal artery
*** Carotid - mid-neck, anterior to SCM
*** Subclavian - supraclavicular fossa
*** Axillary - either lateral to clavicle in deltopectoral groove, or in the axilla
*** Brachial - ACF
*** Radial - wrist
*** Ulnar - requires firmer palpation
*** Common femoral - mid-inguinal point
*** Popliteal - lateral to popliteal fossa
*** Dorsal pedal - between first and second metatarsals (congenitally absent in 10%)
*** Posterior tibial - hollow posterior to the medial malleolus - gentle pressure
* Auscultation
** Normal arteries are silent
** Bruit - turbulent blood flow. Pitch and duration of a systolic bruit are correlated with increasing severity of arterial narrowing, but it's difficult to quantify the degree of narrowing. 
** Bruit in diastole suggests AVF
* Special tests
** Allen test - occlude radial and ulnar arteries, while the patient opens and closes the hand, making a fist, causing blanching of palmar skin. Either artery can then be released to check collaterals.
** Homan's sign - passive dorsiflexion of the foot causing calf pain in calf DVT
** Bancroft sign - tenderness on anteroposterior but not lateral compression of the calf - DVT
** Lowenberg sign - calf pain a/w inflation of blood pressure cuff 
** Buerger's test - check for elevation pallor - a positive test meaning arterial insufficiency, is when the leg turns pale at 30 degrees for 30 seconds. A 'vascular angle' of <20 degrees indicates severe ischaemia. Then, return the foot to a dependent position and check for rubor of dependency.


[[File:Mottled-skin.jpg|thumb|419x419px|Liedo reticularis]]


=== Livedo reticularis: ===

* Macular, violaceous connecting rings forming a net-like pattern
* Secondary to decreased flow leading to hypoxia and collateral formation
* Can be due to PAD, in areas of ischaemia, but more commonly due to vasculitis, calciphylaxis, atheroemboli, hyperviscosity syndromes, endocrine abnormalities, or infection


== Review of patients with arterial disease ==

* Acute arterial occlusion
** Pain, pallor, pulselessness, paralysis, paraesthesia, poikilothermia
** Generalised pain, severe and not well-localised
** Absent motor function - severe limb-threatening ischaemia
** If embolic, there will not generally be a history of claudication or chronic occlusive arterial disease. There will often be a history of AF or previous embolic event
** If thrombotic, there Is generally a history claudication or known vascular disease
* Atheroembolism (blue toes syndrome)
** Ask about progressive renal insufficiency
** Recent catheter-related procedures, but can also be spontaneous
* Lower extremity claudication
** Symptoms associated with walking

== Venous disease ==

* Venous obstruction
** Pain
** Swelling
** Phlegmasia alba dolens
*** Pale, white extremity
*** Frequently seen in post-partum period
*** Collateral veins often seen over upper thigh and abdomen
*** Swelling frequently a/w fever, pain in calf/popliteal fossa/groin
*** Homans attributed this to underlying iliofemoral venous thrombosis
*** Absence of bluish discolouration may be due to rapid discolouration of collateral venous flow
** Phlegmasia cerulea dolens
*** Massively swollen and cyanotic leg
*** Fluid sequestration in the interstitium
*** Won't be able to feel pulses due to oedema
*** Findings c/w compartment syndrome
*** Needs urgent medical and surgical therapy targeted at underlying cause to prevent venous gangrene
*** Should do a Doppler to confirm persisting flow in tibial vessels
* DVT
** Unilateral swelling, discomfort, sense of fullness or pressure
** Need to identify whether provoked or non-provoked
** Look for a difference in calf circumference of 3cm or 2cm in thigh for a high probability of DVT
* Superficial venous insufficiency:
** Incompetent valves at saphenofemoral or saphenopopliteal junctions, with subsequent loss of valvular function along the great and small saphenous veins respectively
** Telangiectasias, reticular varicosities, large ropey varicose veins (which can be traced back to the great or small saphenous veins)

[[Category:Vascular]]