■ Peripheral edema
Assessment of the peripheral vascular system relies primarily on inspection of the arms and legs, palpation of the pulses, and a search for edema. See Chapter 3 for a method of integrating these techniques into your examination of the limbs. Additional techniques may be useful when you suspect an abnormality.
Inspect both arms from the fingertips to the shoulders. Note: ■ Their size, symmetry, and any swelling
■ The venous pattern
■ The color of the skin and nail beds and the texture of the skin
Lymphedema of arm and hand may follow axillary node dissection and radiation therapy.
Prominent veins in an edematous arm suggest venous obstruction.
Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally. Partially flexing the patient's wrist may help you feel this pulse. Compare the pulses in both arms.
In Raynaud's disease, wrist pulses are typically normal but spasm of more distal arteries causes episodes
There are several systems for grading the amplitude of the arterial pulses. One system is to use a scale of 0 to 4, as below; however, you should check to see what scale is used in your institution.
2+ Brisk, expected
1+ Diminished, weaker than expected
0 Absent, unable to palpate of sharply demarcated pallor of the fingers (see Table 14-1, Painful Peripheral Vascular Disorders and Their Mimics, pp. 460-461).
Note that if an artery is widely dilated, it is aneurysmal.
Bounding carotid, radial, and femoral pulses in aortic insufficiency; asymmetric diminished pulses in arterial occlusion from atherosclerosis or embolism
If you suspect arterial insufficiency, feel for the brachial pulse. Flex the patient's elbow slightly, and with the thumb of your opposite hand palpate the artery just medial to the biceps tendon at the antecubital crease. The brachial artery can also be felt higher in the arm in the groove between the biceps and triceps muscles.
Medial aspect of left arm
Feel for one or more 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. If a node is present, note its size, consistency, and tenderness.
Epitrochlear nodes are difficult or impossible to identify in most normal people.
Medial aspect of left arm
The patient should be lying down and draped so that the external genitalia are covered and the legs fully exposed. A good examination is impossible through stockings or socks!
Inspect both legs from the groin and buttocks to the feet. Note:
■ Their size, symmetry, and any swelling
■ The venous pattern and any venous enlargement
■ Any pigmentation, rashes, scars, or ulcers
■ The color and texture of the skin, the color of the nail beds, and the distribution of hair on the lower legs, feet, and toes.
Palpate the superficial inguinal nodes, including both the horizontal and the vertical groups. Note their size, consistency, and discreteness, and note any tenderness. Nontender, discrete inguinal nodes up to 1 cm or even 2 cm in diameter are frequently palpable in normal people.
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