Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 1 Welcome to Mosby’s Guide to PHYSICAL EXAMINATION, 6th edition

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 2 Chapter 15 Blood Vessels

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 3 Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 4 Anatomy and Physiology (1)  Blood Circulation  Vessels circulate blood to and from body and lungs  Great vessels Aorta Aorta Pulmonary artery Pulmonary artery Superior and inferior venae cavae Superior and inferior venae cavae Pulmonary veins Pulmonary veins Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 5 Anatomy and Physiology (2)  Two circulatory systems distribute oxygen to body  Pulmonary  Systemic  Arterial pulse and pressure  Systolic  Diastolic  Pulse pressure Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 6 Anatomy and Physiology (3)  Arterial pulse influences  Volume of blood ejected  Distensibility of aorta  Viscosity of blood  Rate of cardiac emptying  Peripheral arteriolar resistance Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 7 Anatomy and Physiology (4)  Jugular venous pulse and pressure  Jugular pulse components a wave a wave c wave c wave v wave v wave x slope x slope y slope y slope Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 8 Infants and Children  Cutting of umbilical cord necessitates breathing.  Respiration onset expands lungs.  Pulmonary vascular resistance drops; systemic resistance increases.  Ductus arteriosus closes in first 12 to 14 hours of life.  Foramen ovale closes after pressures shift. Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 9 Pregnant Women  Blood pressure decreases.  Peripheral vasodilation occurs.  Blood pools in legs.  Varicosities in legs and vulva may occur.  Hemorrhoids are common. Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 10 Older Adults  Arteries calcify.  Arterial walls lose elasticity and vasomotor tone.  Superficial vessels become more prominent.  Increased peripheral vascular resistance elevates blood pressure. Anatomy and Physiology

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 11 Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 12 History of Present Illness (1)  Leg pain or cramps  Onset and duration  Character  Skin changes  Dizziness  Fatigue  Wakefulness at night Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 13 History of Present Illness (2)  Severe headaches  Onset and duration  Location  Character  History of hypertension  Swollen ankles  Onset and duration  Related circumstances  Associated symptoms Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 14 History of Present Illness (3)  Treatment attempted  Rest  Massage  Heat  Elevation  Medications  Alternative therapies Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 15 Past Medical History  Cardiac surgery or hospitalization  Acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism or St. Vitus dance  Chronic illness Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 16 Family History  Diabetes  Heart disease  Hyperlipidemia  Hypertension (HTN)  Family members with risk factors or peripheral vascular disease (PVD) Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 17 Personal and Social History  Employment  Tobacco use  Nutritional status  Personality assessment  Relaxation  Use of alcohol or illegal drugs  Use of alternative therapies Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 18 Infants and Children  Hemophilia  Renal disease  Coarctation of the aorta  Leg pains during exercise Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 19 Pregnant Women  Blood pressure elevation  Legs  Edema  Varicosities  Pain or discomfort Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 20 Older Adults  Leg edema  Daily living capability  Coping  Claudication  Medications Review of Related History

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 21 Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 22 Equipment  Marking pencil  Centimeter ruler  Stethoscope (bell and diaphragm)  Sphygmomanometer with appropriate-sized cuff Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 23 Procedures  Observe and palpate pulses.  Inspect veins.  Measure blood pressure. Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 24 Peripheral Arteries (1)  Palpation  Carotid  Brachial  Radial  Femoral  Popliteal  Dorsalis pedis  Posterior tibial Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 25 Peripheral Arteries (2)  Palpate for artery characteristics:  Rhythm  Contour  Amplitude  Symmetry  Variations Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 26 Peripheral Arteries (3)  Auscultation over artery for bruits  Temporal artery  Carotid artery  Subclavian artery  Abdominal aorta  Renal, iliac, and femoral arteries  Bruit types  Transmitted murmurs  Obstructive arterial disease Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 27 Peripheral Arteries (4)  Bruit types  Transmitted murmurs  Obstructive arterial disease Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 28 Peripheral Arteries (5)  Assessment for arterial occlusion and insufficiency  Claudication  Pulses  Bruits  Loss of body warmth  Pallor or cyanosis  Collapsed superficial veins  Atrophied skin and loss of hair Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 29 Peripheral Arteries (6)  Three P’s of occlusion  Pain  Pallor  Pulselessness Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 30 Blood Pressure  Systolic  Diastolic  Pulse pressure Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 31 Peripheral Veins (1)  Inspect and palpate jugular vein  Quality and consistency  Effect of respiration  Effect of changing position  Venous compression  Abdominal pressure  Test for hepatojugular reflex  Evaluate hand veins Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 32 Peripheral Veins (2)  Venous obstruction or insufficiency  Thrombosis  Edema  Varicose veins  Assess for  Constant pain  Swelling or tenderness over muscles  Engorgement of superficial veins  Erythema and/or cyanosis Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 33 Infants  Brachial, radial, femoral pulses easily palpable  Try using upper arm or thigh for blood pressure measurements: 60 to 90 systolic normal  Evaluate capillary refill  Very rapid (less than 1 second)  Prolonged (longer than 2 seconds) Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 34 Children (1)  Venous hum is common and has no pathologic significance.  Blood pressure is easy to measure in children 2 to 3 years of age.  Use correct cuff size and record Korotkoff phase 4 until adolescence.  Blood pressure varies with gender and height. Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 35 Children (2)  Hypertension (HTN) in 1% to 3% of children  Early detection and treatment by physical examination is essential.  HTN most often caused by kidney disease, renal disease, coarctation, or pheochromocytoma  Venous thrombosis less common in children Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 36 Pregnant Women  Blood pressure gradually falls until 16 to 20 weeks of gestation, then gradually rises to pre-pregnant levels.  Sustained systolic pressure greater than 140 or diastolic pressure greater than 90 may indicate pregnancy-induced hypertension (PIH). Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 37 Older Adults  Dorsalis pedis and posterior tibial pulses may be more difficult to find.  Loss of vessel elasticity may cause increased systolic pressure.  HTN in older patients is pressure greater than 140/90. Examination and Findings

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 38 Common Abnormalities

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 39 Vessel Disorders  Cranial arteritis  Arterial aneurysm  Arteriovenous fistula  Peripheral atherosclerotic disease  Raynaud disease  Arterial embolic disease  Venous thrombosis Common Abnormalities

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 40 Jugular Venous Pressure Disorders  Tricuspid regurgitation  Atrial fibrillation  Cardiac tamponade  Constrictive pericarditis Common Abnormalities

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 41 Children  Coarctation of the aorta  Kawasaki disease Common Abnormalities

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 42 Older Adults  Arteriosclerosis obliterans  Venous ulcers Common Abnormalities

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 43 Summary of Examination (1)  Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally for the following  Rate  Rhythm  Contour  Amplitude  Auscultate the carotid, temporal, abdominal aorta, renal, iliac, and femoral arteries for bruits.

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 44 Summary of Examination (2)  Measure the blood pressure in both arms with the patient seated; then, in patients at risk for orthostatic hypotension, measure the blood pressure with the patient standing.  With the patient reclining at a 45-degree angle, inspect for jugular venous pulsations and distention; differentiate jugular and carotid pulse waves and measure jugular venous pressure.

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 45 Summary of Examination (3)  Inspect the extremities for sufficiency of arteries and veins through the following:  Color, skin texture, and nail changes  Presence of hair  Muscular atrophy  Edema or swelling  Varicose veins

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 46 Summary of Examination (4)  Palpate the extremities for the following:  Warmth  Pulse quality  Tenderness along any superficial vein  Pitting edema