1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

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

39. 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

40. 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

41. 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

42. 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

43. 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.

44. 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.

45. 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

46. 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