Artery examination

Arterial examination is part of the examination of the cardiovascular system. Together with the examination of the veins, it provides us with comprehensive information about the condition of the patient's blood vessels. In the outpatient clinic, we can use the anamnesis and the basic principles of physical examination (ie sight, touch, listening), especially for quick evaluation, we can also subject the patient to so-called functional tests. For more detailed information, the examination is then indicated using various imaging methods.

History
As part of the anamnesis, we focus on factors related to atherosclerosis both in the patient and within the family. We are especially interested in:


 * disorders of lipid metabolism ( hypercholesterolemia ),
 * diabetes mellitus ,
 * hypertension ,
 * vascular system disorders ( CMP, infarction , thrombosis , embolization ,…),
 * clotting disorders,
 * smoking.



Acute disability
With acute artery occlusion by embolism (more common) or thrombus, symptoms usually progress within hours, especially in patients with poor collateral flow. 50% of those affected develop an acute ischemic syndrome characterized by:


 * severe, severe pain,
 * cold,
 * pallor, followed by marbling and cyanosis ,
 * movement, reflex and sensitivity disorders
 * lack of pulsations.

We register similar symptoms in patients with limb bypass closures. Because these patients often have peripheral nerve involvement in addition to vascular involvement, ischemic syndrome may not be associated with severe pain.
 * Untreated ischemic syndrome progresses to gangrene

Chronic disability [ modify | edit source ]
The symptoms of long-term arterial damage are diverse and are based on a narrowing to the closure of the lumen. Ischemic areas are subsequently formed behind the obstacle. A typical symptom of impaired lower limb arteries is claudication pain ( intermittent claudication ). The patient feels pinching or cramping while walking, which forces him to slow down or stop, which leads to pain relief within a few minutes. Manifestations are most often in the calf, which corresponds to a problem in the femoropopliteal area. When the arteries of the lower leg and leg change, the location of the problem shifts to the sole of the foot, the symptoms in the thigh or buttocks are related to the pelvic arteries or aorta. The claudication interval is important information(section between stops), which corresponds to the distance the patient walks without pain. The interval is used as one of the stages of ischemic lower limb involvement ( ICHDK ). Shortening the interval, ie the distance the patient travels, is related to the worsening of the disease. The underlying symptom is ischemia. Other difficulties can be subjective, such as a feeling of cold in the limb and increased sensitivity to cold, but also objective, such as bouts of white fingers ( digiti morturii ), changes in skin quality (eg hyperpigmentation, flaking, ulceration, etc.) or swelling.

Upper limb involvement is less common and is more typical of finger whitening than pain. Pain is more often associated with strait syndromes ( carpal tunnel syndrome ). Manifestations in the hand area correspond to damage to the arteries in the forearm. A very serious situation can be a narrowing or closure of the subclavian artery before the separation of the vertebral artery. When working a so called upper limb. Thieving syndrome ( subclavian steal syndrome ) when the blood is supplied to the limb by reversing blood flow and. Vertebral artery. The part of the blood intended for the brain is lost in this way, which leads to neurological manifestations such as vertigo, fatigue, syncope. The set of these neurological symptoms can be summarized by the term manifestations of vertebrobasilar insufficiency. Due to the specific anatomical placement of the structures in the area of ​​the key, the first rib and the neck muscles, there may be compression of the entire nerve-vascular bundle for the upper limb. Patients tend to have variable manifestations of vascular and nervous disorders, which often worsen in connection with certain movements, such as hyperabduction.

Glance
We rate:


 * skin quality,
 * adnexa (hair, glands and nails),
 * color,
 * skin surface.

When the arteries are affected, the skin gradually atrophies, the subcutaneous fat decreases and the typical relief disappears (smoothing of the grooves above the interphalangeal joints). Hair thinens, nails deform and grow slowly. Gland atrophy results in dry skin. When the patient is lying down, the limb tends to be paler, the moment he hangs it from the bed, it turns red due to reactive hyperemia. Chronic blood stagnation in the capillaries can be manifested by a red cyanotic color. If we press the place with our finger, it fades. Manifestations on the patch are related to posterior tibial artery patency disorder, on the dorsal leg cyanosis indicates anterior tibial artery involvement. The skin surface can be damaged by abrasions, cracks or ulcers. We often find interdigital mycosis in patients. Typical ischemicGangrene most often begins on the fingertips.

Palpation
We rate:


 * temperature,
 * pulse.

By applying the dorsal side of the fingers symmetrically to both limbs, we mainly evaluate the temperature difference within the limbs. There is a palpable vortex above the larger arteries or above the arteriovenous shunt. We evaluate pulsations in the places of the respective arteries, it is good to orient according to well-palpable anatomical shapes. An intangible or weakened pulse may be associated with arterial occlusion, but also with variability in its course (a. Dorsalis pedis is absent in 8–14% of individuals).

Disappearing pulsation can be a symptom of an acute artery occlusion, which in extreme cases can lead to its loss.

Listening
We evaluate the presence of murmurs, which arise due to changes in blood flow from laminar to turbulent. At 60% narrowing, a vortex is audible, but at 80% narrowing, the murmur disappears. Auscultation to evaluate a. Carotid artery, a. Superficial femoral , and. Popliteal artery and abdominal course of the aorta from the lower abdomen after processus xiphoideus.

A murmur can arise as an artifact if we push the stethoscope too hard and compress the artery during the examination.

Allen's test (modified) [ edit | edit source ]
 https://www.youtube.com/watch?v=gdgomN6TsuE Using this test, we can determine the condition of the arteries distal to the wrist. The test procedure is as follows:


 * 1) We will find and mark the places for palpation of a. Radialis and a.ulnaris.
 * 2) The patient then rhythmically clamps his hand in a fist several times and finally leaves it tightly clenched.
 * 3) In the places we have marked, we compress both blood vessels to prevent blood flow.
 * 4) Let the patient's fist loosen, fingers and palm should be pale. (If they're not, we probably haven't had enough arteries.)
 * 5) During constant compression, the patient hangs his hand and we then release the pressure on one of the arteries. The patency of the artery and the corresponding arc is manifested by reddening of the hand within a few seconds.
 * 6) We repeat the test for the second artery.

Ratschowův test [ modify | edit source ]
This is a position test associated with exertion to examine the lower limbs. We can divide it into three phases.

In the first phase:


 * 1) The patient lying on his back raises his outstretched legs at an angle of 45-60 ° to the mat.
 * 2) He stays in position for 30 seconds.
 * 3) We evaluate the change in the color of the patch, when the limb ischemia fades.

In the second phase:


 * 1) The patient, still in the first phase position, performs plantar and dorsal flexion as quickly as possible.
 * 2) We measure the time that elapses before the calf pain appears and at the same time we monitor the color of the limb.

In the third phase:


 * 1) The patient sits on the bed and hangs his limbs over the edge.
 * 2) Physiologically, the color on the insteps returns within 5 seconds, the veins on the insteps fill within 10 seconds, and the legs are uniformly red within 15 seconds.

The test cannot be used in patients with ICHDK.

Differential diagnosis
Differential diagnostics focuses on neurological history and diseases of the musculoskeletal system.

 References 


 * CHROBAK, Ladislav. Propaedeutics of Internal Medicine-New, completely revised and supplemented edition. - edition. Grada Publishing as, 2007. 243 pp.  ISBN 9788024713090.