VASCULAR PROBLEMS

ASSESSMENT
PATIENT HISTORY:
E.g H/O DM, HTN, cardiac conditions INFORMATION about : prior medications,prior treatment of current problems , H/O relevant surgical or medical treatment procedures involving vascular system.

SOCIAL HISTORY:

Life style patterns tobacco,dietary habits,use of alcohol H/O Onset of symptoms &mechanism of injury Information about work envnt &job skills (pathology &impairment)

SUBJECTIVE EXAMINATION
CURRENT SYMPTOMS including :
Presentation ,behavior,& factors that increase / decrease symptoms Rest pain,how the positioning of LE affects pain information about the vascular status of the patient

OBJECTIVE EXAMINATION
ON OBSERVATION: Look for cellulitis / edema . Presence skin discoloration Cyanosis,pallor, loss of hair,evidence of wound / a previous amputation Gait pattern MOTOR SENSORY STATUS: Range of motion & strength--- effectiveness of muscular activity in promoting blood flow as well as general ability of the patient.

SENSORY TESTING :
Light touch ,pressure
SEMMES-WEINSTEIN MONOFILAMENTS These monofilaments detect the different cutaneous sensory levels. The 5.07 monofilament indicates protective sensation if felt by the patient.

TEMPERATURE:
Various tools such as --RADIOMETER,THERMISTOR,test tubes / basic palpation skills Vascular dysfunction can be identified. Arterial insufficiency skin temperature will be reduced according to severity of diseases. Venous insufficiency there is little or no change in temp.

CIRCUMFERENTIAL (GIRTH) MEASUREMENTS:

To identify and monitor the extent of changes in edema. It should be taken in reference to bony prominences. VOLUMETRICS,a quantitative system to measure edema can also be used.

VASCULAR EXAMINATION:
PULSES: The presence or absence of pulse should be addressed. With PVD palpation of distal arteries is more important than monitoring large vessels of neck & chest. Distal arteries such as brachial & radial arteries along with femoral,popliteal,dorsalis pedis & tibial arteries.

AUSCULTATION :
To identify the turbulent blood flow in the vessel Detection of a bruit may indicate the possibility of partial blockage of that artery. DOPPLER ULTRASOUND: The U.S units operate according to Doppler principle in which a 5,8,/10MHz is transmitted into the desired vessel. The signal is then reflected off moving red cells back toward the Dopplers probe at a different frequency known as FREQUENCY SHIFT. COMMON TEST performed with D.U.S ANKLE BRACHIAL INDEX(ABI)

LOWER EXTREMITY: Dorsalis pedis or posterior tibial arty located. BP cuff placed around the calf and inflated until the signal is heard. At this point,the gauge reading is recorded.
UPPER EXTREMITY: Same procedure is repeated for brachial arty. ABI : LE Pr UE Pr. Normal value = 1.0 / higher.

ABI Ranges
>1.2 1.19 - 0.95 0.94 0.75 0.74 0.50 <0.50

Possible indication
Falsely elevated,artl dis,DM Normal Mild artl dis,intermtt claudn Modr artl dis,rest pain Severe artl dis

SPECIAL TESTS 1. VENOUS FILLING TIME: Patient is positioned in supine affected extremity is elevated to empty blood from supfl. Veins of the limb The patient hangs the extremity over the edge of Rx table(dependent position). The normal filling time is approx 15secs,if > 15secs indicates arterial disease & <15secs suggests venous insufficiency. 2. RUBOR OF DEPENDENCY: Provides info abt both arterial sys & venous sys. The test is same as VFT. Time is recorded for colour of the tested foot to match the stationary foot. Arterial disease it takes 20-30secs(bright red). Venous insufficiency--- colour returns immdy.

CLAUDICATION TESTS: (for arterial invlt) Earliest s/o arterial disINTERMITTENT CLAUDICATION It is a painful cramping mostly occurring in lower leg muscles owing to an insufft blood supply to working muscles. Using a treadmill or an unobstructed level surfacethe C test is recorded as the time or dist at which this painful symptoms occur. CUFF TEST: Performed by placing a BP cuff around lower leg & inflating the cuff. If the pressure >40mmHg,Causes pain,there is a high probability of an active DVT. Forceful squeeze of calf region / passive DF of calf A (+) Ve result is severe pain expressed by the patient (+HOMANS SIGN).

PERCUSSION TEST: Percussion of major supfl vein of LE is useful in determining valve competency. With LE in dependent position Gr.saph.vein is palpated distal to knee with one hand while the vein tapped approx 6-8inches prox to the knee with other. If a wave of fluid is detected distally indicates INCOMPETENT VALVE. TRENDELENBURG TEST: To assess the functioning of valves with in the perforating system. In supine posn: LE is elevated to 75 deg ,tourniquet is placed around thigh to prevent backflow & LE is placed in depd posn.

Venous filling is observed.If immdt filling is noted with the release of tourniq the supfl sys has incompetent valves Veins fill approx 25 to35 secs in depdt posn.
AIR PLETHYSMOGRAPHY: Non invasive vascular examination of both arterial & venous sys. It detects minute changes in leg volumes & can be performed during static,as well as light exercise. It predicts the reoccurrence of venous ulcers. APG can difft b/w superficial & deep venous sys. Other similar devices photoplethysmography (PPG),light reflection rheography (LRR).

STEMMERS TEST: To clarify the the presence of evidence of lymphedema / lymphostasis. Stemmers sign: Inability to pickup a fold of skin at the base of second toe in the affected extremity. Other vascular studies: Venography Arteriography etc;

EVALUVATION:
PT FINDINGS IN ARTERIAL INSUFFICIENCY: Patients history: HTN,or DM. Sx H/o bypass graft, amputation of LE. H/o smoking habit. SUBJECTIVE: C/O: pain on ambulation, rest pain ,LE pain on elevn coldness of feet & hands, color change in digits. OBJECTIVE: Pale appearance of extremities ,temp decrease(distal aspect), Edema may or may not present ,diminished pulse,presence of bruit, Extended time frame VFT, Rubor of Dependency.

PT finding in CHRONIC VENOUS INSUFFICIENCY:

PATIENTS H/O : DM,HTN,CONGESTIVE HEART FAILURE SUBJECTIVE: rest pain or intermittent claudication,Edema , if present decreases with elevn.dark skin color in the affected side. OBJECTIVE: pale appearance of extremities, involved extremities will be warm to touch. Edema ,strong distal pulses. ( + )ve percussion, trendlendburg test. ( - ) ve cuff test.

DIFFERENTIAL DIAGNOSIS : of lymphedema

Venous insuff--- edema resolves within few hours Lymphedema--- edema requires several days to resolve. Skin texture ---- thickened cutaneous fold,soft local swelling.,fibrosis of skin seen in Lymphedema

PROGNOSIS:
Involves the projected level of improvement associated with a pathology as well as the severity & chronicity of impairment.