-The outer layer of the artery is the adventitia

 -connective tissue containing nerve fibers and the vasa vasorum.

1-thrombus formation

2-atheromas,

3-vascular lesions of hypertension

An atheroma

1. begins in the 

2. Complex atheromas are 

3.Plaque rupture may precede

1-intima as lipid-filled foam cells, then fatty streaks.

2-thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken the underlying media. They have a soft lipid core and a fibrous cap of smooth muscle cells and a collagen-rich matrix.

3-thrombosis.

Arm Pulse

1- The brachial artery is palpated 

 2-The radial artery "

1-at the bend of the elbow just medial to the biceps tendon

2-on the lateral flexor surface

3-on the medial flexor surface, although overlying tissues may obscure the ulnar artery

Leg Pulse palpation

1-The femoral artery

2-The popliteal artery 

3-The dorsalis pedis artery

4-The posterior tibial artery

1-just below the inguinal ligament, midway between the anterior superior iliac spine and the symphysis pubis

2-an extension of the femoral artery that passes medially behind the femur, palpable just behind the knee

3-on the dorsum of the foot just lateral to the extensor tendon of the big toe

4-posterior to the medial malleolus of the ankle.

Superficial Leg Veins

1-The great saphenous vein

2-The small saphenous vein

3-Anastomotic veins

1-originates on the dorsum of the foot, passes just anterior to the medial malleolus, continues up the medial aspect of the leg, and joins the femoral vein of the deep venous system below the inguinal ligament

-Blood circulates from arteries to veins through the capillary bed

-Blood pressure (hydrostatic pressure) within the capillary bed, especially near the arteriolar end, forces fluid out into the tissue spaces.

-As blood continues through the capillary bed toward the venous end, its hydrostatic pressure falls, and another force gains dominance. This is the colloid oncotic pressure of plasma proteins, which pulls fluid back into the vascular tree.

-Lymphatic capillaries, which also play an important role in this equilibrium, remove excessive fluid, including protein, from the interstitial space.

-Lymphatic dysfunction or disturbances in hydrostatic or osmotic forces can all disrupt this equilibrium. The most common clinical result is the increased interstitial fluid known as edema 

superficial lymph nodes, accessible to physical examination.

3

 1-cervical nodes

 2-axillary nodes

3-nodes in the arms and legs.

Pre auricular

post auricular

occipital

tonsilar

submandibular

submental

posterior cervical

superficial cervical

deep cervical

supraclavicular

Central

lateral

apical

subscapular

pectoral

epitrochlear nodes- These are located on the medial surface of the arm approximately 3 cm above the elbow and they drain the distal portion of the arm.

(-most of the arm(proximal portion) is drained by the axillary nodes)

Nodes of the Leg

(superficial, palpable system)

 horizontal group-  chain high in the anterior thigh below the inguinal ligament. It drains the superficial portions of the lower abdomen and buttock, the external genitalia (but not the testes), the anal canal and perianal area, and the lower vagina.

 vertical group- clusters near the upper part of the saphenous vein and drains a corresponding region of the leg. 

 -symptomatic limb ischemia with exertion, relieved by rest, suggests 

-distinguish this from spinal stenosis, which produces leg pain with exertion that may be reduced by leaning forward (stretching the spinal cord in the narrowed vertebral canal) and less readily relieved by rest.

-coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces suggests

-“Dry” or brown-black ulcers from gangrene may ensue.

1-risk facors of PAD

6

2-whats warrented if symtoms  and/or risk factors are present

1-older than 50

2-smoking

3-diabetes

4-HTN

5-elevated cholesterol

6-CAD

7-Any first-degree relatives with an abdominal aortic aneurysm

2-examination of ankle-brachial index

Symptoms of aching, numbness, pain in a location suggests the site of arterial ischemia 

1-Fatigue, aching, numbness, or pain that limits walking or exertion in the legs

Screening for renal artery disease

when should we screen

1-HTN

2-unexplained small kidney

3-sudden unexplained pulmonary edema

4-renal function worsening after use of an antiotensin-coverting enzyme or an angiotensin-receptor blocking agent

abdominal aortic aneurysm (AAA)

1-when is it present

2-risk factors 6

-aaa is present when the infrarenal aortic diameter exceeds 3.0 cm (mortality rates increase over 5.5 cm)

-2-smokers

-CAD

-PAD

-Fam History

-HTN

-elevated cholesteol

• Size, symmetry, skin color
• Radial pulse, brachial pulse
• Epitrochlear lymph nodes

• Size, symmetry, skin color
• Femoral pulse and inguinal lymph nodes
• Popliteal, dorsalis pedis, and posterior tibial pulses
• Peripheral edema

-coarctation of the aorta  

-dissecting aortic aneurysm

1. Lymphadenopathy refers to  

2. Try to distinguish between local and generalized lymphadenopathy, respectively, by finding either 

1. enlargement of the nodes, with or without tenderness.

2)- (1) a causative lesion in the drainage area or (2) enlarged nodes in at least two other noncontiguous lymph node regions.

1- A diminished or absent pulse indicates  

2- Chronic arterial occlusion, usually from atherosclerosis, causes 3

1-partial or complete occlusion proximally; for example, at the aortic or iliac level, all pulses distal to the occlusion are typically affected.

2-intermittent claudication , postural color changes , and trophic changes in the skin .

1-Sudden arterial occlusion from embolism or thrombosis causes

 2-The limb distal to the occlusion becomes

3- If collateral circulation is good, only 

1-pain and numbness or tingling.

2-cold, pale, and pulseless. 

3-numbness and coolness may result.

If edema is present, look for possible causes in the peripheral vascular system. 

3

1-In deep venous thrombosis, the extent of edema suggests 

2- when the lower leg or the ankle is swollen the location of the thrombosis is in the 

3-when the entire leg is swollen "

1-the location of the occlusion

2-the popliteal vein

3-the iliofemoral veins 

deep iliofemoral thrombosis. 

Only half of patients with deep venous thrombosis in the calf have tenderness and cords deep in the calf. Calf tenderness is nonspecific and may be present without thrombosis.

1-Varicose veins appear  

2-Their walls may feel  

Many varicose veins can be seen in the leg

1-dilated and tortuous.

2-somewhat thickened.

-The patient should rest with hands in lap, palms up.

-Ask the patient to make a tight fist with one hand; then compress both radial and ulnar arteries firmly between your thumbs and fingers.

-Next, ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale (Extending the hand fully may cause pallor and a falsely positive test)

-Release your pressure over the ulnar artery. If the ulnar artery is patent, the palm flushes within about 3 to 5 seconds.(Persisting pallor indicates occlusion of the ulnar artery or its distal branches)

-Patency of the radial artery may be tested by releasing the radial artery while still compressing the ulnar artery.

Arterial occlusive disease is much less common in the arms than in the legs. Absent or diminished pulses at the wrist are found in 

3

1-acute embolic occlusion

2-Buerger's disease

3- thromboangiitis obliterans.

If pain or diminished pulses suggest arterial insufficiency, look for postural color changes by 

(supine exam)

Raise both legs to about 60° until maximal pallor of the feet develops— slight pallor is normal.

-Marked pallor on elevation suggests arterial insufficiency

 When veins are incompetent, (what tests are not reliable)

-You can map out the course and connections of varicose veins

-With the patient standing, place your palpating fingers gently on a vein and, with your other hand below it, compress the vein sharply.

-Feel for a pressure wave transmitted to the fingers of your upper hand. A palpable pressure wave indicates that the two parts of the vein are connected.

the retrograde filling (Trendelenburg) test,

what ar we testing for

he retrograde filling (Trendelenburg) test,

steps

1-When both steps of this test are normal, the response is termed 

2-When both steps are abnormal, 

1-negative-negative.

*Negative-positive and positive-negative responses may also occur.

2-the test is positive-positive.

1-Atherosclerosis (arteriosclerosis obliterans)

-Intermittent claudication

-Rest pain

2-Acute Arterial Occlusion

3-Raynaud's Disease and Phenomenon

Atherosclerosis (arteriosclerosis obliterans)

Intermittent claudication

-Episodic muscular ischemia induced by exercise,

-Usually calf muscles, but also may be in the buttock, hip, thigh, or foot, depending on the level of obstruction

-Rest usually stops the pain in 1-3 min.

-Local fatigue, numbness, diminished pulses, often signs of arterial insufficiency 

-Raynaud's disease:Episodic spasm of the small arteries and arterioles; no vascular occlusion

-Raynaud's phenomenon:Syndrome secondary to other conditions such as collagen vascular disease, arterial occlusion, trauma, drugs

-Distal portions of one or more fingers. Pain is usually not prominent unless fingertip ulcers develop. Numbness and tingling are common.

-pain gets worse w/ Exposure to cold, emotional upset and better w/ Warm environment

-Color changes in the distal fingers: severe pallor (essential for the diagnosis) followed by cyanosis and then redness

-Clot formation and acute inflammation in a superficial vein

-Pain in a local area along the course of a superficial vein, most often in the saphenous system

-pain is An acute episode lasting days or longer

-Local redness, swelling, tenderness, a palpable cord, possibly fever

Clot formation in a deep vein

Possible swelling of the foot and calf, local calf tenderness

wlakin makes it worse elevation of feet makes it better

-Chronic venous engorgement secondary to venous occlusion or incompetency of venous valves

-Diffuse chronic aching of the leg(s), that worsens as the day goes on, worse with prolonged standing and better with elevation of legs

-Chronic edema, pigmentation, possibly ulceration

-Inflammatory and thrombotic occlusions of small arteries and also of veins, occurring in smokers

-Intermittent claudication, particularly in the arch of the foot, worse with excercise and better w/ rest

-Rest pain in the fingers or toes, chronic, may get worse at night

-both pains get better with cessation of smoking

-Distal coldness, sweating, numbness, and cyanosis; ulceration and gangrene at the tips of fingers or toes; migratory thrombophlebitis

-Pressure builds from trauma or bleeding into one of the four major muscle compartments between the knee and ankle (Each compartment is enclosed by fascia and thus cannot expand)

-Tight, bursting pain in calf muscles, usually in the anterior tibial compartment, sometimes with overlying dusky red skin.

-Pain lasts Several hours if acute (pressure must be relieved to overt necrosis). During exercise if chronic.

-Aggravates pain-Acute:anabolic steroids; surgical complication; crush injury.Chronic:occurs with exercise

-Relives pain-Acute: surgical incision to relieve pressure

Chronic:avoiding exercise; ice elevation

-Tingling, burning sensations in calf; muscles may feel tight, full, numbness, paralysis if unrelieved

-Acute bacterial infection (usually streptococcal) spreading up the lymphatic channels from a portal of entry such as an injured area or an ulcer

-Pain in An arm or a leg, An acute episode lasting days or longer

-Red streak(s) on the skin, with tenderness, enlarged, tender lymph nodes, and fever

Mimics of Peripheral Vascular disorder

Mistaken primarily for acute superficial thrombophlebitis.

2

Acute Cellulitis

Erythema Nodosum

Acute Cellulitis

-Acute bacterial infection of the skin and subcutaneous tissues

-Pain in Arms, legs, or elsewhere with an An acute episode lasting days or longer

-A local area of diffuse swelling, redness, and tenderness with enlarged, tender lymph nodes and fever; no palpable cord

-Raised tender bilateral subcutaneous lesions seen in systemic conditions such as pregnancy, sarcoidosis, tuberculosis, streptococcal infections, inflammatory bowel disease

-pain in Anterior surfaces of both lower legs, associated with a series of lesions over several weeks

-Lesions recur in crops; often malaise, joint pains, and fever

Chronic Arterial Insufficiency (Advanced)

Pain

Mechanism

Pulses

Color

Temperature

Edema

Skin Changes

Ulceration

Gangrene

Pain-Intermittent claudication, progressing to pain at rest

Mechanism- Tissue ischemia

Pulses- Decreased or absent

Color- Pale, especially on elevation; dusky red on dependency

Temperature- Cool

Edema-Absent or mild; may develop as the patient tries to relieve rest pain by lowering the leg

Skin Changes-Trophic changes: thin, shiny, atrophic skin; loss of hair over the foot and toes; nails thickened and ridged

Ulceration-If present, involves toes or points of trauma on feet

Gangrene- May develop

Chronic Venous Insufficiency (Advanced)

Pain

Mechanism

Pulses

Color

Temperature

Edema

Skin Changes

Ulceration

Gangrene

Pain-Often painfulMechanism- Venous hypertension

Pulses- Normal, though may be difficult to feel through edema

Color- Normal, or cyanotic on dependency
Petechiae and then brown pigmentation appear with chronicity.Temperature- Cool

Edema-Absent or mild; may develop as the patient tries to relieve rest pain by lowering the leg

Skin Changes-Trophic changes: thin, shiny, atrophic skin; loss of hair over the foot and toes; nails thickened and ridged

Ulceration-If present, involves toes or points of trauma on feet

Gangrene- May develop

Ulcers of the Ankles and Feet

in Chronic Venous Insufficiency

-This condition usually appears over the medial and sometimes the lateral malleolus. 

-Borders are irregular, flat, or slightly steep. 

-Painful granulations

-Associated findings include edema, reddish pigmentation and purpura, venous varicosities, the eczematous changes of stasis dermatitis (redness, scaling, and pruritus), and at times cyanosis of the foot when dependent. Gangrene is rare.

-This condition occurs in the toes, feet, or possibly areas of trauma (e.g., the shins).

 -Surrounding skin shows no callus or excess pigment, although it may be atrophic.

-Pain often is severe unless neuropathy masks it. -Gangrene may be associated, along with decreased pulses, trophic changes, foot pallor on elevation, and dusky rubor on dependency.

-This condition develops in pressure points of areas with diminished sensation;

-seen in diabetic neuropathy, neurologic disorders, and Hansen disease.

-Surrounding skin is calloused. There is no pain, so the ulcer may go unnoticed. In uncomplicated cases, there is no gangrene. Associated signs include decreased sensation and absent ankle jerks

-Edema is soft, bilateral, with pitting on pressure, on the anterior tibiae and feet.

-There is no skin thickening, ulceration, or pigmentation.

-when legs are dependent from prolonged standing or sitting, which leads to increased hydrostatic pressure in the veins and capillaries; -congestive heart failure leading to decreased cardiac output;

-nephrotic syndrome,

-cirrhosis, or malnutrition leading to low albumin and decreased intravascular colloid oncotic pressure; 

 -drug use.

Edema is soft, with pitting on pressure, and occasionally bilateral.

-Look for brawny changes and skin thickening, especially near the ankle.

-Ulceration, brownish pigmentation, and edema in the feet are common. Arises from chronic obstruction and from incompetent valves in the deep venous system.